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Melanie: Welcome to Back To Health, your source for the latest in health, wellness, and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back To Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine

I'm Melanie Cole. And today, we're demystifying colorectal cancer screening. Joining me is Dr. Lea Lowenfeld, she's an Assistant Professor of Surgery at Weill Cornell Medicine and an assistant Attending Surgeon at New York Presbyterian Weill Cornell Medical Center; Dr. Allison Yang, she's the Linda Horowitz Cancer Research Foundation clinical scholar in gastroenterology and an Assistant Professor in Medicine at Weill Cornell Medicine; and Dr. Andrea Betesh, she's an Assistant Professor of Medicine in the Division of Gastroenterology at Weill Cornell Medicine.

Doctors, I'm so glad to have you with us today and what a great topic. This is awareness of colon cancer, colorectal cancer, so important. Dr. Yang, I'd like to start with you. Tell us a little bit about the prevalence of colon cancer, awareness, what you're seeing in the trends. Speak a little bit about statistics. How many patients are diagnosed with colon cancer each year and how fatal this disease actually is?

Dr Allison Yang: Thanks, Melanie. So colon cancer is the fourth most common type of cancer and represents about 8.2% of all new cancer cases in the United States. In 2020, there were estimated to be about 148,000 new cases of colorectal cancer and an estimated 53,000 people will die of this disease in the past year.

The overall lifetime risk of developing colorectal cancer is about 4%, one in 23 men and one in 25 women. It is more common in men than in women. And it is more common in black patients. And black patients also have a higher rate of death for colorectal cancer. It's most frequently diagnosed in people between the ages of 65 and 74 with the median age being around 67. And unfortunately, we're seeing that rates of colon and rectal cancer are going up, especially in the younger population.

Since the mid-1980s in adults under 40, colorectal cancer rates are increasing by 1% to 2% every year. And rectal cancer is up about 3% every year, since the late '70s in adults under 40. Generally though, rectal cancer does seem to be declining in older adults, 55 and older. And so most cases are sporadic, but the risk does seem to increase with age and patients who have a family history are also at increased risk.

Melanie: Thank you for really summarizing risk factors and prevalence for us today, Dr. Yang. Dr. Lowenfeld, why are we screening for colorectal cancer? Tell us a little bit about the evolution of screening, how this has come about and why it is so important.

DR Lea Lowenfeld: Thanks for having me today. I'm really excited to talk about this because screening for colorectal cancers makes a big difference. And it makes a difference because we're able to detect cancers earlier and we're able to detect actually precancerous lesions and remove those. So it actually can be preventative too.

Melanie: Now, tell us a little bit, Dr. Lowenfeld, about signs and symptoms, because that's the part where people are not quite sure. Some people suffer from hemorrhoids, if you've had babies. I know that I have been scared. I mean, even if you've eaten beets the night before, you could see blood in the toilet and nobody kind of knows the difference of what that red means, when it's important. We're going to talk about guidelines in a minute. But right now, tell us about signs and symptoms and when you feel that it's important somebody contact their primary care provider or a gastroenterologist.

DR Lea Lowenfeld: Great question. So for most colon cancers and most rectal cancers, they're actually asymptomatic and they're found incidentally on a screening colonoscopy. Things that are more worrisome are when patients start to complain of different symptoms and whether that's bleeding or pain or just a change in their bowel habits. Whereas they used to have more regular stools, now they're having more constipation or more diarrhea. And those are definitely things that you want to talk about with your primary doctor, with your gastroenterologist, with your colorectal surgeon. Because some of those things may be something simple like hemorrhoids and something that's related to your diet like beets, but some of those signs and symptoms are definitely more concerning and would prompt evaluation with a colonoscopy.

Melanie: Great points. Really something so important. Dr. Betesh, onto you now. Let's talk about the advantages and disadvantages of colonoscopy itself for colon cancer screening. Speak about the current screening guidelines, because again, these are forever changing. They're different when you look at different organizations. Tell us a little bit about why this is and what do you recommend. What are the most common screenings, the screenings that you feel we should be really looking at?

Dr Andrea Betesh: Yeah, thank you so much for having me. I agree that this is such an important topic to talk about. There are a lot of different screening tests for colon cancer screening. The gold standard test is really the colonoscopy. And this is an examination where your gastroenterologist or colorectal surgeon will actually look at the inside of your colon with a scope, and look for any cancers that could be there and also look for polyps, which are small growth on the wall of the colon. And we care about polyps because we know that polyps can potentially grow into cancer over time.

So the reason why colonoscopies is thought to be the gold standard for colon cancer screening is because not only are we looking for colon cancer, but we're actually preventing colon cancer because we're removing the precancerous polyps.

Another really common test that's just as good at screening for cancer in terms of detecting cancer are stool-based tests. The most common stool-based test is called the FIT or fecal immunochemical test. And for this test, you just submit a stool sample that detects blood in the stool.

And the benefit of the FIT is that you don't have to go through a colonoscopy and everything that is involved with it. But one of the drawbacks of the FIT is that if it's positive, you then need to follow it up with a colonoscopy. So if you're really interested in getting a one-step test, the colonoscopy is the best choice.

Another thing to think about when you're trying to decide between the different tests is how often you need to do it. So a FIT or stool-based test typically is done every single year, but a colonoscopy, if it's normal and there are no polyps, you can 10 years between having them, which is a benefit for a lot of people where you can do it once and not think about it for a long time.

Now, with regards to the guidelines, these are definitely a moving target. It used to be that everybody was recommended to get screened at 50. But we're now talking more about age 45 is the number to start screening. And this is really because of what Dr. Yang talked about in the beginning, which is that we are starting to see more colorectal cancer in patients who are under 50.

And so the American Cancer Society in 2018 updated their recommendations and recommended universal screening for patients aged 45 and the United States Preventative Services Task Force is in the process of updating their recommendation from age 50 to age 45. It's also important to know that if you're African-American, you should definitely start at age 45 and that's been established for many years now.

Melanie: Well, thank you so much, Dr. Betesh, for that answer because it is confusing. And now, Dr. Yang onto you. And I even said this to you off air, this is my favorite of the questions because people are afraid of colonoscopy, that's why they're looking to these other tests. It's a gold standard test. It's so easy. I've had so many of them myself, but the one thing that people are afraid of is the prep. I don't know why. You'll lose a pound for a day or two. So that's kind of nice, but tell us a little bit about the procedure itself and why this is not something that people need to be fearful of, that it's so easy, so quick, takes no time at all.

Dr Allison Yang: Definitely, Melanie. And I can definitely understand being worried or anxious about the procedure. The procedure itself usually takes about 30 minutes or so. And you're asleep for the whole thing. So you get a great nap. And when you wake up, the thing I hear most often from patients is, "When are we going to get started?" And my response is always, "We just finished. You had a great nap." So the procedure itself is actually quite relaxing for most patients. And they have a great nap with the anesthesia that they get for the procedure.

The prep happens the day before the procedure and patients will often say that this is harder than the procedure itself. Generally, patients are on a clear liquid diet for the entire day before the procedure. And this means that you can't have any solid food, but you can have plenty of light or clear-colored liquids, and you can even have some Jell-O if you really want to chew something.

Usually, in the afternoon, you start drinking the colonoscopy prep. And the good news is we have many, many different types of prep available on the market right now. And many of them are much smaller volumes of prep liquid than they have been in the past. So at about 4:00 or 5:00 PM, you usually drink half of the prep, follow it with some water or some glasses of juice. And at some point, you start going to the bathroom, because the goal is we want to clear out the colon so that your proceduralist can get a good look at the wall of the colon the next day.

Usually, you drink the second half of the prep later that night or early in the morning before your procedure. And you continue having some liquid stools after you've taken the prep with the goal of completely clearing out your colon.

Patients will come in to the procedure. They'll meet with our nurses, go over the history, meet with the doctor and the anesthesiologist. And then you'll go in for the procedure. And everybody usually wakes up feeling just fine and ready to go home and know that you've had your colon checked out and that we've done our part and you've done your part to try and reduce your risk of colon cancer.

Melanie: Agreed completely. And it is, listeners, so easy. And as she says, you get this great nap and it's just a very easy thing. So don't hesitate if it's the procedure that you are concerned with. Now, onto the results. Dr. Lowenfeld, what should a patient expect after this screening? Tell us a little bit about the results. What are you looking for? What is a polyp? What does it mean? Tell us about all that.

DR Lea Lowenfeld: So after you have your colonoscopy, the endoscopist will be able to tell you exactly what they saw right away, because they're able to see the inside of the colon, take pictures, show you the pictures afterwards, and you'll get those results before you even leave the building.

What we're looking for in colonoscopy are mostly polyps and polyps are benign growths. They come in different shapes and sizes. They're more common as people get older. And most of them are incidentally found, meaning that they don't cause any symptoms. We just find them on the colonoscopy. And in most cases, when we find them, when they're small, they can be removed in their entirety.

And the reason we that we remove them is because they can progress to a cancer. And this progression is something that happens over years. And so that's why we recommend getting a colonoscopy every couple of years. Depending on what kinds of polyps you have, what size they are and how many you have, that would dictate how frequently we would recommend getting a colonoscopy in the future.

These do also run in families, so it is important to know if your family members have had any polyps on their colonoscopies.

Melanie: Great points and so important to note. And Dr. Lowenfeld, sticking with you for a second. Tell us about some of the exciting advanced endoscopic techniques that you might be utilizing if somebody does have polyps or difficult polyps or you find colon cancer. Tell us a little bit about some of the exciting techniques that you're using today.

DR Lea Lowenfeld: Great. This gives me a great opportunity to talk about some of the new things that have been developed in the past couple of years and that we're continuing to work on, because what we're trying to avoid is having patients need to have a surgery for a benign polyp. And one of the most common reasons that people were getting surgery for benign polyps were because they were large and they were not able to be removed with the colonoscopy.

But in the past couple of years and even more recently, we've been developing new techniques to remove polyps that are bigger, polyps that are flat and they extend over a long surface area. And so this allows us to avoid having to have a surgery and having to have a resection of the colon.

So for a cancer, the recommendations are still to get a colectomy, because it is important to know the exact depth of the cancer and whether it's spread. And that would be something that you would know with the colectomy. But in that case, when we do diagnose these in the early stages and when they're found when they're very small, the colectomy can be curative. And so you wouldn't need to go on to get any further treatment.

Melanie: It's fascinating, the technology today and what you can all do. I'd like to give you all a chance for a final thought and something that you would like to let the listeners know. So Dr. Betesh, how does someone decide which colon cancer screening test is right for them? Can you please reiterate the importance of knowing your family history to help figure out when you should begin screening and what type of test based on the ones that you mentioned before that we should be getting?

Dr Andrea Betesh: Yeah, absolutely. I think the real takeaway here is, because colon cancer is so common and it is so fatal for many people, the best screening test is the one that you're willing to do. So if you are willing to do a colonoscopy, generally we do consider that the gold standard. But if colonoscopy does not sound like something you're willing to do, meeting with your doctor and getting a stool-based colon cancer screening test is absolutely something you should consider.

And when it comes to family history, it's really important to know what's in your family history. So if there's colon cancer in the family history or a lot of polyps in the family history, for those individuals, we strongly encourage them to go forward with a colonoscopy because we do know that there are some genetic components to this risk. So talking to your family and understanding what your risk is, is very, very important. And if you're just not sure, you can always speak to your primary care doctor or seek with a gastroenterologist or a colorectal surgeon to make a decision together as to what the best test for you is.

Melanie: So important. And Dr. Lowenfeld, tell us really what's exciting in the field of colon cancer. And what would you like listeners to know about preventing it, if they can?

DR Lea Lowenfeld: Great. Yeah, that's what we're trying to do. We're trying to prevent colon cancer and we're trying to cure colon cancer. And the first step in that is trying to do it with a colonoscopy so that we can get things before they even turn into a cancer. As Dr. Betesh mentioned, there are a lot of screening tests and those are good for patients who have no symptoms and do not have a family history.

But as we mentioned before, if you have concerning symptoms, that would prompt first a discussion with your doctor, and that would really indicate that you need to get a colonoscopy and that the other screening tests may not be appropriate for you.

And with the colonoscopy, you know, the goal is to try to remove things when they're small, when they're not even cancers, and follow that up with interval screening, and to find cancers when they're curable and that's the most exciting part.

Melanie: Well, it certainly is. And Dr. Yang, last question to you. What would you like listeners to take away from the importance of discussing any concerning symptoms with your physician, whether it's your primary care provider or finding a gastroenterologist and what you'd like them to know about what you can do for them at Weill Cornell Medicine?

Dr Allison Yang: Absolutely. I think the main takeaway here is there's no symptom that's too minor or too embarrassing to bring up with your physician. This is what we do every day. We want to talk to people about their gastrointestinal symptoms. We want to know if there's anything that's different, that's changed, that you're concerned about. We want to hear it all. So there's no need to be shy. And be sure to discuss anything that you're worried about with your primary care physician or with your gastroenterologist.

The colonoscopy and other types of colon cancer screening tests are all great tests. And you should certainly consider doing at least one of them, so that you can help decrease your risk of colon cancer. The technology has come so far and we've gotten so much better at finding early cancers and at preventing cancers by removing these precancerous polyps. And it's something that you should definitely take advantage of.

What I hear most often from my patients when they wake up from a colonoscopy is, "That was so much better than I expected. The hype was way worse than even the prep or the procedure itself." And that had they known how easy it was, they would have done it a long time ago. So talk to your doctor about getting colon cancer screening.

Melanie: What an informative episode. You doctors really covered the whole gamut of this type of screening and why it's so important. It was so informative. Thank you so much for joining us.

And Weill Cornell Medicine continues to see our patients in person as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine.

That concludes today's episode of Back To Health. We'd like to thank our listeners and invite our audience to download, subscribe, rate, and review Back To Health on Apple podcasts, Spotify and Google podcast. For more health tips, go to WeillCornell.org and search podcasts.

And parents, don't forget to check out our Kids' Health Cast. I'm Melanie Cole.  

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