Transcription:
Preventing, Diagnosing and Treating Colon Cancer

Dr. John Leonard:  Welcome to Weill Cornell Medicine CancerCast, conversations about new developments in medicine, cancer care and research. I'm your host, Dr. John Leonard. And today, we'll be talking about preventing, diagnosing and treating colon cancer. I'm really happy to have today's guest, Dr. Felice Schnoll-Sussman. She's a gastroenterologist and Director of the Jay Monahan Center for Gastrointestinal Health at Weill Cornell Medicine and New York Presbyterian Hospital.

Dr. Schnoll-Sussman is well-known for her clinical expertise in research in digestive cancers, as well as her advocacy efforts to increase awareness for the importance of screening. So Felice, it's great to have you here. It's really an important topic and I know an evolving topic. And having heard you speak on this in the past, I know it's something that you're passionate about and really knowledgeable about. So I think this is going to be a great session for our audience to hear more about these issues. So thanks for joining us.

Dr. Felice Schnoll-Sussman: Thank you so much. It's my absolute pleasure, especially in March, which is Colorectal Cancer Awareness Month. So it's just wonderful to have the opportunity to talk about this topic.

Dr. John Leonard: So Felice, I want to start by asking you how you found yourself working in this area. Among all the areas of medicine, what drew you to gastroenterology and in particular dealing with issues around colon cancer, screening and prevention?

Dr. Felice Schnoll-Sussman: Thanks for asking that question. It's so interesting. I think a lot of what happens to us in life is really not by accident. But first of all, I really define myself as an internist. And I love just taking care of the whole patient. And I knew I wanted to be a doctor from, I would say the moment I popped out -- even as a little kid, I remember thinking about issues that affected people and lots of people, especially as young kids, they had tummy problems. Their tummy hurt them, "My tummy hurt me," things like that. And even as a young child, I never had that, but it was something that I associated with medicine.

And as I got older and started to really think about medicine and becoming a physician, I was really interested by the GI tract itself because there were so many organs. So unlike other things, which are all fantastic, but let's say cardiology, it's the heart and maybe I thought about kidney doctors are just for kidneys. For gastroenterologists, they had all these wonderful organs, the colon, the stomach, the liver, the pancreas and that really was interesting to me.

And then as I got older, I realized there were very few women that were in gastroenterology. And especially when we're talking about organs like the colon or having an examination of your colon or looking at an organ that maybe goes through someone's bottom, I really realized that many women actually wanted to be seen by women or just the fact that there were no women in the profession and that also drew me to it as well.

And then in terms of specifically colorectal cancer and colorectal cancer awareness, this is really sort of the Grand Poobah of gastroenterology. You know, when we think about gastroenterologists and probably one of the major impacts that we can make as gastroenterologists, you have to think about colorectal cancer and colorectal cancer screening and just all the wonderful improvements that we've made in defeating or in tackling this cancer in our world.

Dr. John Leonard: So let's jump in more specifically to colon cancer and the issues around there. I know that people have maybe a varied knowledge about how prevalent it is and how it presents itself. People think about blood in the stool. They think about pain or weight loss, but what are the signs and symptoms? And how common is this? How much do people need to worry about this in general?

Dr. Felice Schnoll-Sussman: Colorectal cancer is actually fairly common. So I would say if you were in an average room of 25 people, one out of 25 women, that's about 4% chance in one's lifetime, one out of 25 women will develop colorectal cancer. And the chances are a little bit less in men. It's about one in 23 men, so that's a fairly common cancer. And if we just look at the past year, there were 95,000 new cases of colon cancer diagnosed in the United States. So this is a common cancer.

In terms of the symptoms, the truth is many people with early colorectal cancers and definitely polyps, which I'm sure we'll have a chance to talk about, many of them are asymptomatic. And so that's why screening is so, so important. And that's why we do screening in people that just have no symptoms because you can have no symptoms and still have certainly a polyp inside your colon.

But I would say the most common symptoms for colorectal cancer are rectal bleeding. And that could look like many different things. So rectal bleeding could be bright red blood that you see. It could be maroon-colored stools. It could even be black stools. And many times, there's actually blood in the stool that you can't see at all. And some tests for colon cancer are actually to check the stool for this silent blood, we call it occult blood in the stool.

Other symptoms that people can get would be things like the change in weight that you didn't expect to happen, that all of a sudden you start losing weight. Or unexplained belly pain or even a change in your bowel habits. Let's say you're someone that goes to the bathroom every day like clockwork. And now, all the sudden, you find yourself not able to go to the bathroom or go into the bathroom every five days where it's really hard to go to the bathroom. Or let's say you're someone who's typically always constipated, you have to take laxatives to go to the bathroom or, you know, it's really a chore to try to go to the bathroom. And now, all of a sudden, you go into the bathroom a lot, or the stools are really loose or diarrheal. That could be another sign of colon cancer as well.

And many people even think about the way that the stool looks. Normally, gastroenterologists, I mean, we love to talk about stool. But when we talk about colon cancer, many times people will think about something like a thin stool and that's because, if there were to be a cancer, sometimes now the colon has become narrow and it's sort of squeezing down on the stool and only these thin stools that could sort of look like a pencil can actually get through.

So basically, Dr. Leonard, there's many different signs and symptoms of colon cancer. Not all of them certainly are colon cancer, but if you were someone that were to newly develop these or these were to become something you hadn't had and there's a change, that would be something you probably should present to your doctor to discuss.

Dr. John Leonard: So one question I have for you relates to a sense that is out there that colon cancer seems to be occurring more for people at younger ages. And I know you oversee the Jay Monahan Center which is named after Katie Couric's husband who passed away at a young age from colon cancer several years ago. But when you look at people like Chadwick Boseman, Stuart Scott, some of the celebrities out there that have unfortunately dealt with this at what seemed to be young ages, is this a real phenomenon or are we just hearing more about young people?

Dr. Felice Schnoll-Sussman: I'm so glad that you brought this topic up because it really is an important topic. When I initially became a gastroenterologist, if we had someone who presented, a young person, let's say someone in their 20s who presented with rectal bleeding, I would nine times out of 10 assume that was just bleeding from something like a hemorrhoid, totally benign. And we probably would maybe treat them for something like that and not even do an exam. Well, I can tell you there is absolutely a change in the age that people are now presenting with colorectal cancer. And we've been watching this phenomenon over the past two decades or so, and there is absolutely a frightening increase in the onset of colorectal cancer and people at young ages.

Now, we used to talk about starting colorectal cancer screening at the age of 50. And most of that was because we wanted to be able to catch polyps a little bit later in life. At this point in time, we truly are seeing individuals that are in their 20s and 30s that are presenting with colon cancer. And specifically, a lot of those young people, they're presenting with colorectal cancer that's low down in the rectum. Something that almost, if you were to do an exam just to feel inside the rectum, sometimes you would actually even be able to touch that cancer.

We really don't even know why this is happening. And there is an enormous amount of effort being put into trying to understand why this is occurring, looking at things like early exposures when someone was very young or medications or fertilizers or changing dietary habits. And obviously, we recognize that there is an increase in obesity in our society. And even trying to understand whether or not that is a link to this.

But right now, we really have not been able to figure out the reason why, but there truly is an increasing incidence in young-onset colon cancer. And a really important message if you're a young individual and you start to experience any of those symptoms that I just reviewed, you really do need to present to your physician for an evaluation as well because colorectal cancer might actually be the culprit behind what's going on.

Dr. John Leonard: You mentioned obesity as a risk factor. What are some of the other risk factors? And are there any so significant that you would change your screening pattern?

Dr. Felice Schnoll-Sussman: Well, I would say that the most important risk factor and probably the thing that could be most impactful for someone is to understand their family history. If we were to ask all of our patients to tell us about their family history and specifically their family history of colon cancer, that is probably the biggest risk factor for someone.

So even just one first-degree relative like mother, father, sister, brother, child, that type of relationship, that close proximity of a relationship, is a signal that you could be at an increased risk for colon cancer and that we might need to actually start to screen you even younger than what the guidelines say.

Other things that could be individual important risk factors are certain diseases that people could have. So there are conditions, things like inflammatory bowel disease, which are inflammatory diseases of the colon. Their other names are called Crohn's disease or ulcerative colitis. These are diseases where the inflammation actually can change the lining of the colon. And those individuals are at increased risk for colorectal cancer as well.

There are some other risk factors that are hereditary risk factors. And there are some individuals that actually have changes in their genes. We call them mutations and those mutations can actually lead to a very high risk for them getting colon cancer. And that too can be identified by understanding your family history and seeing whether or not there are people in your family that have died young.

You know, when we talk about young from cancers, we're usually talking about less than the age of 50. But anything like that are really important things to sort of know about for people that are young, that maybe haven't spoken to their family members about, you know, "What did grandma or grandpa die from?" Or, "I heard that your sister died, my aunt died of something? What did she die from?" Those are the things that are really important questions because they really can give clues to your own genes and your own personal risk factors.

Dr. John Leonard: So I want to move now to how we screen for colon cancer. And I know that colonoscopy is the mainstay of that and I want to ask you about that experience and how that goes for people typically in a second. But what are the alternatives to colonoscopy? And what are the pros and cons of choosing perhaps one of those alternatives?

Dr. Felice Schnoll-Sussman: Well, that's a really important question. And first of all, the most important thing that I think we can also get out of this is that the best test is a test that gets done. So we'll go into colonoscopy, but it's not the only test and it's not the only test that maybe even be presented to you by your physician. So people shouldn't think, "If I haven't had a colonoscopy and my physician is screening, will I have something else?" That could be completely, totally appropriate.

Most colon cancer screening is done by one of two ways. One is looking in the colon, which is what the colonoscopy is and the other are exams that are at times looking at your stool. But there are ways to actually look at your stool. And some of the tests could potentially be done in a doctor's office, but they really should be done at home. And we're looking for two things in your stool. And one is looking for blood in your stool. So there are tests that are done in your home after you passed the bowel movement and actually you put a little bit of stool onto a card and it gets sent back to the doctor for evaluation, they're called FIT tests. Those are the most common tests and those are actually looking for some breakdown products of blood in the stool.

And the reason why we do that is because many times, especially if a polyp is getting big or if there's a cancer in your colon, they have a tendency to bleed. And that blood can get picked up in the stool and that's a signal that there's something going on in your colon. And then if that were to come back positive, you would have to then go for a colonoscopy because the test is only telling you about a problem maybe in the colon.

Now, there's been a lot of direct-to-consumer advertising and, you know, I was watching a couple of weeks ago the Super Bowl on TV, and I saw ads for this other type of test called Cologuard, and the ad, the very, very cute little box with a person on it that's sort of dancing. And that test is another test that's done in your home. It's also a test that's done on a freely passed stool. And you actually put this little device on your toilet bowl seat and you pass a stool and then you wave a little stick on top of it.

And basically, that gets sent back to the company. And they're looking for not only blood in the stool, but they're also looking for those mutations, those little changes in sort of the genes that can happen in people that are risk for colon cancer or that are seen in the cancer that now come into the stool and the company that does that is able to look for those cancerous changes, those mutations as well as blood in the stool.

Some other tests that can be done are radiology tests. And one is called a barium enema. It's not done that often, but it's a type of a test where you go into a radiology suite and they actually put a little speculum in your bottom and they put some air and some contrast up the bottom. And they can actually outline the colon and look to see if there are any abnormalities, any growth in the colon, like a polyp or cancer. And then you would need to go on for colonoscopy as well.

And then there's another test called a virtual colonoscopy. And that basically is a radiology test as well. It's usually done by a special kind of CT scan or an MRI. And the radiologist actually is able to sort of recreate the way the inside of your colon looks and also look for any abnormalities that might be growths, like a polyp or a mass.

So when you really think about these tests, and the pros and cons, I would say, in my mind are the ones that are done at home are things like the stool-based tests. Those are done totally at home. Those are easy. You don't have to take a day off from work. You don't have to get sedation like when you do for colonoscopy. But they're not as sensitive, meaning they are looking for findings that are associated cancer, but they are not able to see inside of your colon. And they're not as good. They're not as strong as doing a colonoscopy. So you have to do them more frequently. So for instance, that FIT test has to be done every single year. And the Cologuard is done in general every three years. And then the other tests like that virtual colonoscopy, also it's not as good at being able to detect polyps. They have to be a little bit bigger. So you have to do that more often.

Colonoscopy, on the other hand, that test requires a preparation and I'm sure we'll go through that. But during the colonoscopy, not only are you able to see a polyp or let's say cancer, but you're actually able to take out a polyp and biopsy a cancer. So all the tests have a different pros and cons. But like I said, if someone is on the fence and they are concerned about doing a colonoscopy, certainly go and get any tests now that you feel comfortable to do, because any test is better than no test.

Dr. John Leonard: So that brings us to colonoscopy itself. And first, I'm curious what percent of people actually get colonoscopies as they should? And I'm guessing it's not as high as we'd like. And what's involved in going through a colonoscopy? I'm sure some of our audiences has experienced it and others be contemplating it as we talk about it now. So how do you tell people kind of what's in store if they move forward with it?

Dr. Felice Schnoll-Sussman: In terms of the first question, which I think is also important, is we're not at a hundred percent. And so, in the United States, only about 68% of adults that should be screened for colon cancer have received screening for colon cancer. So we are just not there yet. And there is many people that have access to these different procedures. You know, they have doctors, they have insurance and they just haven't had one of these tests. So one of the things I would love for us to do is to sort of dispel the myths or try to help people really understand these tests, that they're not frightened to have them done. Because when you really understand them, they're not scary. I mean, it's an imposition, but everyone can go through this.

So in terms of colonoscopy, I kind of like describing it in a certain way and I don't like to make light of anything because it's a medical test. But, in some way, we have to have a little bit of light in life. So I like to describe going for a colonoscopy a little bit like going for a day at the spa. So basically, this is a day that you take, which is really about you. So even if you have very busy work life or children at home, or you're in school or stressed from other things, this is a day that is sort of dedicated to you.

You have an opportunity to clean out your colon. There are many people who love the feeling of how kind of they feel like they reset their GI tract and they kind of feel light. And some people even lose a little bit of weight with just doing the prep itself.

And then you come into the test and you get some sedation. So I'm just going to kind of go through with you what the experience is. So anyone who comes in for colonoscopy, one of the things that they must do for colonoscopy is to clean out the colon from stool. So this is the part that most people hate to do.

But what I can tell you is it's one day out of your life and really, after you've gone through it, what people are really scared about is they think it's going to be painful. It's really not painful. I mean, most of these preparations that you take, because you would take a whole bunch of laxatives the night before, and some the morning of the test. You'd go to the bathroom a whole bunch of times. There are some people that get a little bit nauseous from it, but many people just go through it and it was just one night of their lives.

Then, they come in. And in general, they have some oxygen put on them. Usually, we check their blood pressure. We check their pulse. We bring them in the room. And the thing that people should realize about colonoscopy is there is no one that is, during colonoscopy, looking at your backside. People are covered up during the exam. It is an exam where the only people that are in the room are the medical professionals, and basically the doctor during most of the exam is actually looking on a screen, not even looking at your backside.

And during the exam, a scope is gently inserted into the bottom, into the rectum. And it's navigated by watching the scope, which has a camera and a light source on it. We actually navigate it up the colon all the way to the top of the colon, to where the colon and the small intestine meet. And then after we get to the top of the colon, we slowly withdraw the scope. And we're looking to see if there are any polyps or let's say cancer there.

And at the time of the colonoscopy, we're were able to actually identify those polyps and remove those polyps. And then we send them to the pathologist, so they could be looked at under the microscope to make sure that there's no cancer in those polyps or to look at any biopsies to see if there's any cancer in those biopsies.

Now, after the procedure, what people truly are is they're hungry and they are relieved and many people remember nothing about the procedure. They wake up and they just cannot believe that the test is done. I can't tell you how many times patients say to me, "Okay, Dr. Schnoll, when is it going to start?" And I'm sort of smiling at them because the whole test is over. And then I sort of ask them what do they want to eat, because they're certainly happy and they're hungry. And then they go home and we tell them not to drive or make major decisions because they got some station. But basically, very shortly after the exam, they're feeling totally back to themselves. And certainly by the next day, they were able to do any of their normal activities..

Dr. John Leonard: So after the colonoscopy, what are kind of the results that someone has? They can have a perfect or a clean colonoscopy or they can have other findings. Kind of what are the categories of that just at a high level?

Dr. Felice Schnoll-Sussman: So there's basically two main findings. Well, there are three. The first is they had nothing and their exam is clean of any polyps or any growth. And then, in general, if someone is an average risk person, meaning they have no family history of colon cancer or no other risk factors for colon cancer, we can tell them they can come back in 10 years for the next colonoscopy.

Now, in some people we can find early polyps and those polyps can be completely removed and that actually takes away someone's risk of ever getting cancer from that polyp. Unfortunately, there are some people, and this is really the vast minority of people who at the time of the colonoscopy, we can actually identify a cancer. We will look to see where the cancer's located and we will take biopsies of the cancer at that point in time. And then that would then help us to decide upon what treatment planning they may need.

The really good news, however, is that if someone is coming at an age-appropriate time for colorectal cancer screening, very few people, very few people have cancer. Now, in general in terms of finding polyps, I would say there's probably about 30% at least or somewhere between 25%, 35% of both men and women at the time of their colonoscopy that we might identify a polyp, which could be pre-cancerous. It could have given us a risk of getting cancer, but we're able to completely remove it.

So the exam itself is what we call both diagnostic and therapeutic, meaning you could see and find the area of abnormality. And many times at the time of the colonoscopy, we're actually able to completely take it out, thereby preventing colon cancer from actually developing.

Dr. John Leonard: It sounds like in a way finding a polyp is, I don't want to say, the best of all worlds, but it's got to be, I guess, rewarding to some degree in that, you know, that you needed the colonoscopy and that you dealt with the issue right then and there, as you say.

Dr. Felice Schnoll-Sussman: You know, it's interesting, before the podcast today, I was doing procedures and I did several colonoscopies today. And in one of the patients, there was sizeable polyp on the right side of the colon. And I turned to the nurses in the room and, knowing that we were doing the podcast today, I turned to her and I said to her, "This is the reason why we do colon cancer screening."

When I looked at that polyp and the size of the polyp and the location of the polyp, it wasn't a hundred percent that this person was going to get cancer from it. But by looking at the polyp, I knew that this was a type of a lesion that had a really high chance of going on to colon cancer. And it's true. Not only was it satisfying for the patient, but I have to tell you, I actually felt really satisfied because I knew we really made a difference in this person's life by doing that colonoscopy.

Dr. John Leonard: So I want to come back to you about the age of when screening should begin. And what are the current guidelines as to when screening should begin? And are there groups of people that perhaps should be handled a little bit differently?

Dr. Felice Schnoll-Sussman: Well, this is really a very timely question because just recently the American Cancer Society had put out new guidelines as a result of the younger onset that we were seeing of colorectal cancer. They actually changed their guidelines and said that instead of starting screening at the age of 50, that we should decrease the age to 45. And recently, other large national societies like the American College of Gastroenterology are also endorsing decreasing the age to 45.

Now, for a very long time, some of the national societies actually encouraged starting colorectal cancer screening at 45 in African-Americans because there was a higher incidence of younger onset of both polyps and cancer. But now, the current recommendation is that in anyone average age, men, women, regardless of race, to actually start at the age of 45.

Now, if you have family history, like we mentioned before, so for instance, if you have a first-degree relative who had colorectal cancer for instance, if your father had colon cancer, we typically would start at the age of 40 or 10 years younger from the age of that person presented. So if your parents had been very young, when they developed colon cancer, let's say they were 45 when they got colon cancer themselves, we might actually recommend starting at 35 just because we realized there's something really different about that person. But in average risk people at this point in time, we are endorsing starting colorectal cancer screening at the age of 45.

There are some insurers that are still catching up to these recommendations so there's some people that have insurance coverage that might only still allow them to start at the age of 50. That being said, I'm fairly certain that other people follow this trend as well and all the insurance will eventually encourage starting at 45.

Dr. John Leonard: So I want to wrap up this part of the discussion by just asking if you find a cancer, how are most cancers treated? And obviously, it depends on the stage and the size and the spread. But at a high level, what's new in that regard? I know there are a number of new surgical techniques and new drugs and things of that nature, but what are you most excited about in that regard?

Dr. Felice Schnoll-Sussman: I would say one of the things that's really exciting about this field is that there are many techniques that we can actually even do endoscopically, meaning through the scope itself to be able to take out even cancers at this time. And this is something that we really had never been able to offer individuals where we found early-onset colon cancers.

And most people, when you actually had that meant that you were destined to have surgery, you know, sort of like a big surgery. At this point in time, that is very different. And so for many patients, there is the opportunity to have surgeries that are very minimally invasive, laparoscopic surgeries where we can take out a whole half of someone's colon laparoscopically, no big surgery, no big scars. But even endoscopically, there's opportunities to do things like that as well.

And then, in the arena of other more targeted therapies, there are many new medications that are now on the forefront for individuals that are so much more encouraging than what we used to think about in terms of standard treatments for people with colorectal cancer. And there are many new treatment options that are targeted therapy for individuals based upon actually in some ways, thinking about sort of like genetics of their colon cancer and who they are as individuals and certain personalized medicine approaches based upon the type of cancer that individuals have.

So, the arena right now in terms of colon cancer for individuals really provides a lot of hope to some people, not only with early cancer, but also individuals with previously aggressive type colorectal cancers where there are new and important treatment options available.

Dr. John Leonard: I want to ask you, you know, many people may get their colonoscopy by their physician or their gastroenterologist, but I think some of this discussion has highlighted the importance of access to a multidisciplinary team, kind of like what you have at the Jay Monahan Center here at Weill Cornell in New York Presbyterian.

Sometimes these are just cut and dried where it's the patient and their gastroenterologist and everything is great. But it strikes me that having access to genetic counselors, imaging, radiologists, surgeons, medical oncologists nutritionist, it seems like all of those things can be very important for some people, depending on their situation.

Dr. Felice Schnoll-Sussman: I could not agree more with you. When this center was initially opened, a big portion of the reason why it was opened was really out of the experience that Katie Couric had when she and her husband was trying to navigate through this extraordinarily challenging time. Here, she had a young husband who was diagnosed with colorectal cancer. She had access to everything. I mean, this is Katie Couric. But even for her, she realized how challenging it was to do so.

And so at the time of our lives, when someone may be does not feel well, they are very scared. There is an enormous amount of information that is being thrown at them. There are many different physicians that they might need to be seen. It can be incredibly helpful to go to a place, a hospital, a center that has this experience in a way for a patient that is somewhat seamless.

And so what we offer at our center and there are other centers that certainly do things like this as well, but for someone that has a disease like colorectal cancer, you need number one to start to get treated and you need to get treated quickly and you need to be seen by multiple different physicians like, for instance, a gastroenterologist, perhaps a colorectal surgeon, maybe an oncologist. You might need a radiation oncologist. Certainly those individuals, if there was a family history colon cancer, you could be concerned that this is genetic and you want to see a genetic counselor. And many patients that have colon cancer may have eating issues or issues with things like diarrhea or belly pain, and the need to be seen by a nutritionist.

And having a multidisciplinary approach where you're able to see more of these practitioners in a way where they actually talk to each other and help put together a synthesized type of teamwork approach for the patient where the patient is in the center. It's a patient-centric approach, you know, really understanding what does this patient need? What is their family like? What is their family dynamics like? So that you can really understand the patient and help them not run around and make all of these appointments on their own.

And the other thing that's important about a multidisciplinary approach is that the physicians talk about each of the patients, like I said, in conferences where the patient's case is presented. And then you're able to understand all of the new treatment options, because perhaps there are clinical trials that the patient is more appropriate for, or perhaps there are new surgical techniques that that patient's appropriate for. And just having a lot of really thoughtful people in one room that are focused on the patient, it really makes an enormous difference in the care of someone. And for me personally, in terms of my tenure here in the medical center, I would say that has been one of the most rewarding aspects of my time practicing here.

Dr. John Leonard: Well, I want to end how we began. And that was you highlighting the fact that March is Colorectal Cancer Awareness Month. And I want to ask you in my last question really what's the key takeaway that people need to keep in mind as they think about this issue in this area, in their own health and that of their family?

Dr. Felice Schnoll-Sussman: So one thing that I always try to say to people is don't die of embarrassment. And I know that sounds a little strange, but there are people who walk around with symptoms. Like for instance, they have diarrhea or they have blood in their stool where they're just embarrassed that someone might have to do an exam by looking up their bottom.

So the two things that I would just implore people is don't die of fear and don't die of embarrassment because now the horizon is so incredibly bright for new diagnostic tools, earlier detection, better ways to resect lesions, better treatment options, but we can only do it if the patient comes to the doctor.

The other thing is learn about your family history. If you do not know what your mother or father had or what your grandparents perhaps died from, you should ask today to find out what that is, and you should tell your children what they have in their family history.

And the last is any test that gets done is the right test. So if you do not think that you're ready for colonoscopy at this point in time and all that you think that you can handle is potentially doing the stool-based test in your home, do a stool-based test in your home. Perfect. If there's something there, we'll deal with it. If it's not, you won't have to do it again for a year. But for those of you that are interested and feel able to do a colonoscopy, it is a safe, extraordinarily effective test that is done in a respectful way. Most patients don't even know that they had it done. And the worst part is maybe the prep, but anybody can get through it.

Dr. John Leonard: Well, thanks so much, Felice. It has been great to have you and really some fabulous takeaway advice and really words of wisdom from an outstanding doctor. So thanks for joining us today. We really appreciate it.

Dr. Felice Schnoll-Sussman: Dr. Leonard, thank you so much for allowing me to come on the show. I really enjoyed having an opportunity to share with you these things. It really is important to me to get the word out. I know it can make a difference in so many people's lives and get screened.

Dr. John Leonard: Well, thank you. And I want to invite our audience to download, subscribe, rate, and review CancerCast on Apple podcasts, Google podcasts, or online at weillcornell.org. We also encourage you to write to us at cancercast@med.Cornell.edu with questions, comments, and topics you'd like us to cover more in-depth in the future. That's it for CancerCast, conversations about new developments in medicine, cancer care and research. I'm Dr. John Leonard. Thanks for tuning in.