SPEAKER_01: 0:01

Welcome to the Healthy Matters Podcast with Dr. David Hilden, primary care physician and acute care hospitalist at Hennepin Healthcare in downtown Minneapolis, where we cover the latest in health, health care, and what matters to you. And now here's our host, Dr. David Hilden.

SPEAKER_03: 0:18

Hey everybody, and welcome to episode two of season five of the podcast. I am David Hilden, your host, and you know there are plenty of things that we'd probably all rather talk about than our intestines and our colon. Like literally anything. But here's a sobering fact: colon cancer is one of the most common cancers in the United States. There's a hopeful part though. It's also one of the most preventable. I get it that people want to put it off, but the truth is a little screening can go a long way and it's not nearly as bad as you might think. Catching colon cancer early can literally save your life. So today we're gonna sit down once again with my colleague at Hennepin Healthcare, Dr. Jake Matlock. He is a gastroenerologist and knows a thing or two about colon cancer. Jake, welcome back to the podcast. Thanks, David. It's great to be here. Start us off. Can you just explain what colon cancer is? How does it arise in people?

SPEAKER_02: 1:09

Sure. Colon cancer is uh a an abnormal growth that occurs within the lumen or within the tube of the intestinal tract in the portion of the intestine called the colon, which is the last roughly five to six feet of your intestinal tract. It's the part of your intestinal tract that's responsible for waste processing. So it's not one that we think about uh very often or like to talk about in polite conversation, but it is one of the most common cancers in both men and women in this country. And so it's an important topic for everyone to be aware of.

SPEAKER_03: 1:42

So your colon being your large intestine, the last five feet. Say more about that if you could. What does your colon do except move yucky stuff through it?

SPEAKER_02: 1:49

Trevor Burrus So if you can imagine the intestinal tract as a whole is responsible for absorbing nutrients from the food that we eat, but there's a lot of waste that runs through us that is not useful to our bodies, not useful for our nutrition. And so as a result of that, about three liters of liquid waste is delivered to the colon every day, and the colon is responsible for processing that liquid waste, reabsorbing the water from it, and turning it into solid stool.

SPEAKER_03: 2:17

Aaron Ross Powell You said liquid waste, though. I ate a steak the other night. That wasn't very liquid. It wasn't how did it get to be liquid?

SPEAKER_02: 2:23

Uh so the digestive process uh starts actually uh as soon as you put food in your mouth. Uh the salivary enzymes start the digestive process and and through the actions of your upper intestinal tract, from your mouth through your uh stomach and the upper part of your small intestine, food is broken down from solids uh first into smaller pieces of of solid material and then ultimately down into liquid, occasionally with some solid chunks uh without getting too graphic. You know, some people are putting together while they're listening to this. But but by and large, what is delivered to the colon is is kind of a pea soup consistency mixture. Trevor Burrus, Jr.

SPEAKER_03: 3:02

Well, that's actually a good consistency uh um thing, pea soup, because that's roughly what it is. It's not water. It's not water. But it's not what it's not your stool yet. It's not the solid stuff. Correct. And so your intestines then get rid of all the water?

SPEAKER_02: 3:14

Aaron Powell, so your colon is responsible for reabsorbing the water from that stool stream, and that's useful because if you know if you can imagine three liters of liquid waste coming through every day, if you couldn't reclaim that water, number one, you'd be spending most of the day in the bathroom. And number two, if you weren't in the bathroom, you'd probably be trying to replace all the fluids that you were losing. So really your colon allows you to function in the world.

SPEAKER_03: 3:36

Yeah, and and I know uh you know, occasionally during this podcast, we'll we'll make a couple jokes here and there, but people who have loose stools, who have chronic diarrhea or any diarrhea know, know that it changes your day, it changes your week, it changes your life. So you know, when your colon's not working, that comes into dramatic focus then. So is there a connection between colon cancer and rectal cancer? Rect your rectum being the last few inches of your colon?

SPEAKER_02: 4:01

That's correct. Your rectum is the last few inches of your colon. It's anatomically distinct in a few ways. For one, it has a different innervation that allows you to sense when you need to have a bowel movement. Uh, that's that's where that sensation comes from. The rectum is also anatomically different from the colon just because of its location down low uh within the bowl of the human pelvis. But from a physiologic standpoint and and more from the standpoint of cancer, uh the distinction is not terribly important. I hesitate a little bit there because the distinction is important when it comes to treatment, which is a little farther down the line, but but uh but beyond that, I think we you can kind of lump them together.

SPEAKER_03: 4:43

So we use the word colorectal cancer in that case. Correct. Okay, so how do these cancers start? And something about polyps. Why don't you talk about polyps if you could?

SPEAKER_02: 4:51

Aaron Powell Yeah. So the the the overwhelming most common pathway for the development of colon cancer is through these small growths in the colon called polyps. Now, polyps uh can take a variety of forms, not all of them are associated with the development of colon cancer, but the kind that that people most commonly think of, which are called adenomatous polyps or adenomas, are associated with growth and ultimately transformation into colon cancer. For all intents and purposes, you can think of this as the as a sole common pathway for the development of colon cancer. There are some very rare exceptions, but that's that's really the the major pathway.

SPEAKER_03: 5:27

So why do why do we grow polyps? Or why do some people grow polyps?

SPEAKER_02: 5:31

Aaron Powell It's a great question. Uh you know, if you look statistically speaking, somewhere around a third of adults will have polyps. And so it's a very common thing for adult humans to have. A third. A third. Yeah. And and some people would suggest that's even an underestimate of the prevalence. There are risk factors that can increase a person's uh likelihood of developing polyps. Some of them are genetic or familial risk factors, some of them environmental. But even in the absence of any identifiable risk factors, we still find polyps quite commonly in asymptomatic people.

SPEAKER_03: 6:06

So one of the perks of being a doctor and working at a major metropolitan center like I do is that you have friends and colleagues who will let you like look in on what they do. So I have been there when you have done a colonoscopy. It's fascinating. But could you talk listeners through when you're doing a colonoscopy? And we'll talk more about who should get a colonoscopy later, but talk us through when you are looking in someone's intestines, what does a polyp look like?

SPEAKER_02: 6:28

So uh a polyp looks uh like a small break in the contour or texture of the lining of the colon. So normally your colon is is a smooth, moist lined structure. It looks a little bit like the inside of your cheek, honestly. And if you can imagine uh something growing uh on that lining that looks almost like a mole on the skin. So it breaks the contour, it's a little bump. Uh over time, uh those bumps will get bigger and and more geographically interesting. They get uh ridges and bumps within them. Occasionally they'll even grow a stalk and look almost like a mushroom coming up off the lining of the colon.

SPEAKER_03: 7:06

And they're little, right? These aren't big. They look huge on your screen, because you're looking at them on a screen, but they're not huge. They do.

SPEAKER_02: 7:12

I mean, we have we have uh thankfully through the improved technology, through high-definition cameras and better lighting, we have been able to detect much smaller polyps than we used to. So now the limits of our detection are probably on the order of one to two millimeters in size. Uh they can get quite large. Uh, you know, some of them are uh uh uh five centimeters even, so uh so fifty millimeters in size, so that's about two inches in diameter. Whoa. Uh so that's that would be considered a giant polyp, but uh but from a certain perspective, that's still not very big. It's a couple of inches.

SPEAKER_03: 7:45

From a from a sesame seed to a big grape or a small golf ball, even. Yeah. Yeah. Yeah. Wow. Okay. So how long does it take for one of these polyps, those that might turn into colon cancer, how long does that take?

SPEAKER_02: 7:58

So to go from no polyp through the process of forming a polyp, having it grow, and ultimately transform into a colon cancer is probably somewhere on the order of 10 years. So there's a window there, a long time. There is a pretty good window. And that's really the only reason that colon cancer screening works, is because we know what the precursor thing is, what it looks like before it becomes cancer, and we have an adequate time lag to be able to get in there and do something about it.

SPEAKER_03: 8:25

Which is what a screening test needs. If there's if you don't know what the precursor looks like and you can't catch it in time early enough and there's nothing to be done about it, then a screening test doesn't work. This checks all the boxes. Exactly. Okay, so before we get into how you get screened, let's talk a little bit about colon cancer itself in the population. How common is it?

SPEAKER_02: 8:44

Well, colon cancer is currently the third most common cancer in both men and women in the United States. So if you think about the actual numbers, uh in this country every year, approximately two million people are diagnosed with some form of cancer. Colon cancer accounts for 150,000 of those. So that's just under 10 percent of uh the cancers diagnosed in this country each year. If you look at how many people die from cancer, roughly 600,000 people die each year from some form of cancers. And roughly 55,000 of those are colorectal cancers. And so colorectal cancers do take up a larger s share of the deaths from cancer than they do of cancers themselves. And and when you consider the fact that, again, it is the third most common cancer in both men and women, it's a substantial public health problem. Trevor Burrus, Jr.

SPEAKER_03: 9:36

It totally is. And many people think of, well, I'm not old enough for that. We used to think of it it's people over age 50, and in fact, that's who we used to screen. Everybody over 50 should get some kind of screening done. But everybody knows somebody or has heard about somebody younger getting colon cancer. Do we know why that might be?

SPEAKER_02: 9:53

I don't think we have the full answer yet. Uh certainly there's a lot of speculation about uh environmental factors, changes in our food stream, changes in our uh health habits that are probably playing a role. Currently, the guideline suggests that we should be screening everyone at age 45, which is, as you pointed out, younger than what uh was the case when you and I did our training. There is not, as of yet, a guideline for screening people younger than 45, unless the person has identifiable specific risk factors or symptoms related to their colon. But as you pointed out, the incidence in younger people is rising. It is still an order of magnitude lower than in older individuals, but uh but it it is a cause for concern and attention, I think.

SPEAKER_03: 10:40

Aaron Powell What are those risk factors? You mentioned risk factors. Is it genetic? Is it the steak I ate the other day? What is it? It might be the steak I ate.

SPEAKER_02: 10:48

It's unfortunately the same litany of risk factors that doctors seem to uh harp on for just about everything.

SPEAKER_03: 10:55

So are you gonna tell me to eat right, don't drink, and like exercise?

SPEAKER_02: 10:59

Aaron Powell I'm afraid so. Uh, Dr. Pottskill. Yeah. So from a dietary perspective, uh uh alcohol, tobacco, and uh a diet high in red meat uh place people at substantially increased risk for colorectal cancer. Uh and I love the roller grill at the gas station as much as anybody, but that hot dog is not doing you any favors uh from the standpoint of colon cancer risk.

SPEAKER_03: 11:24

Aaron Powell Yeah, that's a questionable life choice on many levels to get the hot dog at the gas station, Jake.

SPEAKER_02: 11:29

I think we've both been there, though.

SPEAKER_03: 11:33

Yep.

SPEAKER_02: 11:34

Looking uh away from specific uh environmental exposures, uh obesity is also a risk factor uh for colorectal cancer. And then there's there's the familial risk factor. If you have relatives uh who have colon polyps or colon cancer, particularly if it is at an early age, and here I'm talking about under the age of 60, uh, then you are at increased risk and you should let your your healthcare provider know that.

SPEAKER_03: 11:59

Let's pivot to that then. Let's talk about the nuts and bolts of screening. So you already touched on who should get screened by age. Is there anything more we need to say about age? It's 45 for everybody, and some people younger. Who are the younger ones?

SPEAKER_02: 12:18

And I think that uh without getting too much into the weeds, it's important to to make note of first degree relatives with colon cancer or polyps. And by first degree relatives I mean parents, siblings, or children. If you have second degree relatives, so grandparents, aunts, uncles, cousins who have colon erectal cancer, that may be important uh depending on their age and the number of uh second-degree relatives that are uh involved. Uh, but that gets a little bit more complicated and it's probably worth a focused discussion with your healthcare provider. Aaron Ross Powell, Jr.

SPEAKER_03: 12:54

Let's talk about the types of screenings you can do. We're going to talk a little bit about, or a lot of bit, about colonoscopy, but it's not the only kind. So if you could talk us through about what the options are for people.

SPEAKER_02: 13:04

Sure. There are there are a lot of options now, and I think as you and I have discussed on multiple occasions in the past, the most important factor is choosing a test that you are actually willing to do. So getting screened uh in one way or another is more important than how you do it. I think that the modes of screening can be broken down into endoscopic tests, of which colonoscopy is the most common and the most widely available, and then stool-based tests, which are tests that use samples of a person's stool collected usually at home to look for either blood or certain uh changes in the DNA in shed cells in the stool to look for signs of uh potential cancer or precancerous changes. The other modalities that are out there, and here I'm thinking mainly about imaging modalities like CT colonography have not really panned out uh as well uh uh in in their actual prevention of colon cancer, and so are probably best reserved for people who are unable to do one of the other tests.

SPEAKER_03: 14:10

Aaron Powell So talk us through stool-based testing just briefly.

SPEAKER_02: 14:14

Sure. So the the uh tried and true uh stool-based tests uh uh rely on the detection of blood or blood products in the stool. So here you may be familiar with what are called hemacult cards. These are small cardboard cards that you put a little bit of stool on, you mail it in, and some of the things that you're doing.

SPEAKER_03: 14:34

That means you don't need a big amount of stool on there. Trevor Burrus, Jr.

SPEAKER_02: 14:38

Please no. Please no. Uh the uh cards then have a developer that's placed on them and they they uh uh change color uh with the presence of blood. Kind of old school that one. Aaron Ross Powell That's very old school. And I would say that most places are no longer using straight hemocults, but uh the hemacult has been, has evolved to include uh testing for DNA markers. So now we have the FIT test and the IFOB test, both of which, again, are looking for changes to the uh the shed cellular material in stool. More recently, we've uh had the ability to do something called a cola guard test. Uh this is a more extensive stool-based test. It involves the collection of a larger volume of stools, so it's not just a little bit on a card, but actually a whole collection kit that gets mailed to a patient uh for collection at home. Uh this has a a wider uh array of markers that it is looking at within the shed stool and does provide some uh longer duration of protection. So the the downside of the stool tests has always been that you have to repeat them every year. Uh, but with the cola guard, that uh interval is extended to three years. Aaron Ross Powell And then you have to do something if it's positive. Aaron Ross Powell That's correct. If if any of the stool-based tests show a positive result, then the recommendation is to have a direct optical examination of the colon with a colonoscopy. That's when a guy like you steps in. That's when a guy like me steps in.

SPEAKER_03: 16:07

So we have been talking with uh Dr. Jake Mattlock, he's a gastroenterologist, and we're talking about colon cancer. When we come back from a short break, we are going to talk about how it's diagnosed, what the experience of a colonoscopy is like from the guy who's actually doing it. So stay with us, we'll be right back.

SPEAKER_00: 16:25

When Hennepin Healthcare says we're here for life, they mean here for you, your life, and all that it brings. Hennepin Healthcare has a hospital, HCMC, a network of clinics in the metro area, and an integrative health clinic in downtown Minneapolis. They provide all of the primary and specialty care you'd expect to find, as well as services like acupuncture and chiropractic care. Learn more at Hennepinhealthcare.org. Hennepin Healthcare is here for you and here for life.

SPEAKER_03: 17:02

And we're back. Okay, so colonoscopy sort of gets a bad rap with some people. It's like, oh my gosh, this is gonna be horrible. Can you talk us through the process of colonoscopy from PrEP to what you do?

SPEAKER_02: 17:12

Sure. So the the PrEP is the part of the colonoscopy experience that most people find most distasteful. Uh in order to look at a person's colon, we have to clean it out. I have to be able to see the walls of your colon clearly in order to detect these very small abnormalities. As such, we have people drink a large volume of liquid that the body can't absorb and can't use. And so, as such, that liquid just runs through you. It creates a tidal wave through your intestinal tract.

SPEAKER_03: 17:44

Like a radiator flush.

SPEAKER_02: 17:45

It overwhelms the colon's ability to reabsorb water, and so it it literally just flushes everything out. The volume that people have to drink varies depending on the type of preparation that is prescribed, but is typically between a half gallon and gallon of liquid. I wish I could say that it tastes really good. It doesn't. Chill it, drink it a little slower, and maybe throw a straw. That's what I heard. Trevor Burrus, Jr.: There are any number of tricks. Use of a straw, use of cold, walking and moving around to try to try to keep stuff moving through you so it's not coming in.

SPEAKER_03: 18:19

And can't you make your life a little better by not eating heavily in those days, leading up to it?

SPEAKER_02: 18:24

Aaron Ross Powell, we do recommend modifying uh the diet in the the three to five days leading up to the PrEP. And the goal of the dietary modifications are to try to reduce the volume of uh waste that's in the intestinal tract. It's a little counterintuitive because normally we are telling people to eat a lot of fiber, it's good for your health and so forth. But in order to really reduce the volume of stool that needs to be cleared out, we do we do typically suggest a low fiber diet just for that few days prior to the preparation.

SPEAKER_03: 18:52

Aaron Powell What about preps that don't involve uh all that drinking of fluids? People talk about the little, isn't there one that's just uh 64 ounces? And isn't there even one in pill form or something? What about all of those?

SPEAKER_02: 19:03

Aaron Powell There are low volume preps, and um those are still creating a tidal wave that runs through the gut. I mean, it you cannot get around the fact that you have to flush everything out in order to see. But for the low volume preps, they are relying on taking fluid from a person's body and sucking it into the intestinal tract to create the volume for the flush rather than having the person consume it.

SPEAKER_03: 19:28

Okay.

SPEAKER_02: 19:28

Uh that's more palatable uh for many people. It also does run the risk of creating some electrolyte imbalances because you are stealing, you got to steal the liquid from somewhere. And so if you're not uh consuming the liquid, uh then your your body has to has to sacrifice that liquid. The nice thing about the higher volume preps, as as challenging as they can be, is that they are, by and large, volume and electrolyte neutral. So that makes them much more own body. Yeah, it makes them much safer for for people to consume again with the caveat that it can be somewhat challenging because of the volume.

SPEAKER_03: 20:03

Okay. So I'm all prepped up. I've been on the toilet all night long. My colon is pristine. And I come into your office in the GI lab, and what happens?

SPEAKER_02: 20:14

Well, first of all, we're gonna make every effort to make you comfortable while you're there. Uh, we recognize that it's an uncomfortable situation to be in. It can be kind of awkward if you've never been there before. And so we want to make you feel welcome. We're gonna bring you in, we're gonna introduce you to our team. Uh so you're gonna meet the nurse, the tech, and the doctor who's gonna be involved in your procedure. We'll put an IV in one of the veins in your arm, and that is to allow us to administer medication to keep you comfortable during the test, and then we'll bring you into the procedure room. Once we're in the procedure room, we'll administer small doses of sedating medications, and those are again just to keep you comfortable and relaxed during the test. Uh, it's uh certainly more pleasant for you. It's also better for me as the person performing the test if you're relaxed and not moving around so that I can get a good look. Yeah. The better look I get. Aaron Powell, Jr.

SPEAKER_03: 21:06

Are most people out sleeping?

SPEAKER_02: 21:09

I would say the majority of people are somewhat awake during their colonoscopy, although it is also the case that most of them do not have much, if any, recollection of the event. And so uh whether or not a person is awake kind of depends on who you ask. If you ask the person, they'll usually tell you they slept through it. But if you ask the operator, they'll typically tell you no, they didn't.

SPEAKER_03: 21:30

Really? So, because here's the deal. In all full disclosure, I had my colonoscopy here and I know everybody. I knew the doctor doing the test, I knew the nurse, and I go, hey, I'm gonna watch this thing. I'm really, I'm good. This is gonna be interesting. I'm gonna watch my colon on that screen. I don't remember 10 seconds of it. I was probably pretty sedated, but kind of maybe I wasn't as squirmy as I would have been had I not been.

SPEAKER_02: 21:51

Yeah, I I had mine here as well. I had mine without any sedation, and uh it's not as it's not as difficult a an experience as I think most people expect it to be. It's really just not that difficult. Yeah, that's you're kind of a hero there. I can't believe that I think the hero is the person who did the I think so okay.

SPEAKER_03: 22:10

So you're on this thing. Just real briefly, talk us through what you put the scope all the way as far as it'll go in, and then you'll look on the way out. Is that is that fair to say?

SPEAKER_02: 22:18

That's correct. So the the part of the test that can be uncomfortable is is inserting the scope all the way to the top of the colon. Again, that's about five or six feet uh of intestinal tract. And so getting in there around all the different twists and turns that the colon takes through your abdominal cavity can be a little bit challenging.

SPEAKER_03: 22:34

Be honest with me. Is it like playing a video game? A little bit. I mean, I'm not gonna do that. I'm seeing your hands on this. You've got all these things, you're looking at a video screen, you're turning, you know, you're you know, there there are there are a lot of fun things in medicine.

SPEAKER_02: 22:45

This is definitely one of them.

SPEAKER_03: 22:46

Um people say, why do you go in to being a gastroenterologist? You're looking at all the nether regions of people, and here you are saying it's kind of fun. It is kind of fun.

SPEAKER_02: 22:56

And uh, you know, typically to get to the top of somebody's colon takes one to two minutes. Uh and then really it's on the way back out, as you as you said, that we're doing the examining part of the uh uh of the test. And on the way back out, what we're doing is we're trying to make sure that we get a look at every surface of the colon. Your colon is not a long straight tube, it's got twists, turns, folds. It's kind of shaped like a question mark, I always thought. So it's shaped like a question mark, and the structure is somewhat like an accordion. So it's got it's got rings of muscle and and somewhat ballooned out areas in between those rings of muscle. And so we really need to take our time to look behind each fold, around every turn, uh, so that we can detect as uh as many polyps as And do puff it up, puff it up with air. Aaron Powell We do. Uh typically we'll use either air or carbon dioxide to inflate the colon uh to allow us to see a little better. We try to take as much of that gas back out as possible.

SPEAKER_03: 23:49

Because it's coming out somehow. It's coming out somehow. So don't go back to work. Yeah.

SPEAKER_02: 23:54

Well, and if you do, you can blame me for the whole day.

SPEAKER_03: 23:57

Uh okay. The colonoscopy is done. How do you diagnose abnormalities?

SPEAKER_02: 24:02

Aaron Powell So as we talked about earlier, uh, the main thing that we're looking for during a colonoscopy are these small growths called polyps. Those are diagnosed based on visual inspection. So I have to be able to recognize a polyp and and uh and and see it when it's present. If we see polyps, our job is to take them out, which we do during the colonoscopy. It all happens in one fell swoop. How do you do that? Typically, we'll use either uh a small lasso of wire called a snare, or on occasion, with really small polyps, we can use a biopsy forceps to just pluck them out. But I think that that most polyps are removed with a a small snare. The scope has a channel that runs through it that we can insert a variety of instruments through, and uh one of those is is this small snare and then on the end of like a five-foot-long wire? Yeah, yeah. I mean it's it's a it's a catheter and it has a uh a handle at one end that a tech will open and close the snare with, and and we open the snare, place it around the polyp, and then close the snare, either just using it as a a knife to cut through the polyp, or on occasion, if uh if the polyp is larger and we're worried about bleeding, we'll pass an electrical current through that snare to to cauterize as we cut the polyp off.

SPEAKER_03: 25:17

Okay, so you've cut this thing off or you you have cauterized it off. It's sitting there in the colon. How do you get it out?

SPEAKER_02: 25:22

Depends on the size. Uh for smaller polyps, we can apply suction and suck them up through the same channel that the uh the instruments run through. For larger polyps, we'll put a different instrument through the channel that looks like a fishing net and and simply put the polyp in the net, pull the pull the scope all the way out, dump the polyp out uh of the net and go back into where we were and keep moving.

SPEAKER_03: 25:45

Okay, so you get this thing out, you've got a little piece of tissue, I suppose you put it in a specimen container. How is colon cancer then diagnosed? What happens to that polyp next?

SPEAKER_02: 25:52

Aaron Powell So everything that we take out, whether it's a polyp or simply a sample from a larger lesion that we actually are concerned is a cancer, gets sent down to the pathology lab where uh the the specimen is fixed, sliced, and stained to be examined by one of our pathologists. Uh so when I take a polyp out of somebody, I put it in a jar, I wave goodbye to it, and then I wait. And I uh typically 24 to 48 hours later, I will get a result from the pathologist saying, this is a polyp, this is not a polyp, this is a cancer, this is not a cancer.

SPEAKER_03: 26:26

And the majority of the lesions you take out are some type of polyp, right? It's it isn't that you're usually taking out and sending to the lab and they say this thing's already cancer.

SPEAKER_02: 26:36

That's correct. I think it's a good idea. You know, we do, as I said, find polyps in roughly a third of people who come in for for this exam. So that's a very common finding. To find an actual colon cancer on a routine screening exam is much less common. Uh I would say that that, you know, if I'm in the endoscopy lab and and doing colonoscopy all day, every day, uh, Monday through Friday, I'll probably find one cancer in a week.

SPEAKER_03: 27:02

And a lot of polyps.

SPEAKER_02: 27:03

And a lot of polyps.

SPEAKER_03: 27:05

Which is the reason we're doing these. You want to find those polyps because you're in that 10-year window and you got rid of it. Exactly. And comment on this if you could. The one advantage to colonoscopy. Well, there's many. There's some advantages to colonoscopy about other screening methods. But one of them is that when you see one of these polyps, you actually removed the problem in real time.

SPEAKER_02: 27:24

Aaron Powell That's correct. I mean, colonoscopy is is nice because it is both a screening exam and a therapeutic uh maneuver. Because that polyp is not going to bother you in the future, assuming you got it. Correct. Once it's gone, it's gone. And uh, you know, we when we identify somebody as a as a person who is a polyp former, we will typically advise them to come in on a somewhat more frequent basis. But the the individual polyp that we have removed is no longer a threat to them. It's gone. Currently, for people with small polyps, the recommendation is to come back in seven to ten years, uh, which is a change from just even five years ago. Uh, and that is uh a reflection of the fact that uh number one, we now understand that polyp growth is slow. And number two, the detection of polyps has gotten better, and so the ones that we're finding are smaller than they used to be. Aaron Powell Okay.

SPEAKER_03: 28:15

Uh we're not going to get in a lot of detail about colon cancer treatments, but at a higher level, somebody is diagnosed with an actual cancer. How are what are the treatment options that they might at least have to consider?

SPEAKER_02: 28:27

The most important treatment for colorectal cancer is resection. And for early stage colon cancers, uh, resection can be curative. Cut it out. Cut it out. And often resection is recommended even for more advanced colon cancers, which is different from a lot of types of cancer. And the reason for that is that you don't want the primary cancer getting so big that it blocks off the intestinal tract. And so, really, resection is something that should be considered and on the table as an option for any colon cancer. It's not always the right thing to do, but it should always be under discussion.

SPEAKER_03: 29:04

And when you're talking about resection, you refer to one of our colorectal surgeons who isn't cutting out the tumor, right? They're cutting out a segment of your intestine. Is that a fair statement?

SPEAKER_02: 29:15

They're cutting out the segment of the intestine that contains the tumor, and and they want to get several centimeters of normal, healthy colon on either side, as well as the lymph nodes that drain that segment of colon, because the lymph nodes are going to be the first place that the cancer spreads out if it has left the colon. And so getting those lymph nodes that drain that particular area is important so that the pathologists can again look at those lymph nodes to see if there is any sign of spread. And that helps us to determine if the resection was adequate to treat the cancer or if more uh treatment would be recommended. And then they just hook up the two ends? That's correct. Usually uh they are able to do what's called a one stage operation. Which means that they take out the section of colon that has the cancer and then hook the two ends back together. There are some circumstances, thankfully not very common, where uh they have to do a two-stage operation where they take the section out with the tumor in it and then bring the intestinal tract out to the skin for uh a short period of time, usually a matter of a few weeks to a few months. Um you have a bag in a couple of things. You have a bag that a person has to wear and then only later go back and hook things back together.

SPEAKER_03: 30:28

Aaron Ross Powell So resection is the primary thing for many or if or even most cancers. What about chemotherapy and radiation? That's on people's minds a lot.

SPEAKER_02: 30:35

Aaron Powell Yeah. So chemotherapy is one something that is used frequently in uh colon cancer if it has spread beyond the colon and occasionally, depending on the the uh microscopic appearance of the cancer, even if it has not spread beyond the colon. The use of radiation is principally limited to rectal cancers, and uh without getting too much into the weeds, that has to do with the fact that the rectum is, as we alluded to earlier, in the pelvis and therefore in a relatively fixed, non-moving location. The rest of your intestines kind of move around in your abdominal cavities, it makes them very hard to target with radiation. But the fixed location of the rectum makes it a good candidate for radiation therapy.

SPEAKER_03: 31:18

Aaron Ross Powell So what's the prognosis in general terms, obviously, for someone who has their cancer caught early? And then obviously, what's the prognosis if it's caught late?

SPEAKER_02: 31:30

So with an early stage colon cancer, the prognosis is actually quite good. It is one of the cancers that we can reasonably talk about curing rather than we don't use that word much in cancer, but we still can't, yeah. Very rarely use that word. But but with early stage colon cancers, I think it's a reasonable label. With later stage colon cancers, uh, particularly those that have spread even beyond lymph nodes and to other organs within the abdominal cavity or chest, the prognosis is not as good. Uh it it it becomes unrealistic to talk about cure. Uh, and rather we are talking about uh slowing the progress of the disease, slowing the advancement of the disease.

SPEAKER_03: 32:10

Which explains the the high numbers that you gave at the top of the episode. Before I let you go, Jake, you've mentioned um how preventable this cancer is and the importance of screening. So what what's on the horizon that that's given you hope um about treatments or diagnosis or what's the future look like?

SPEAKER_02: 32:27

Aaron Powell Well, I think that that the thing that has become clear to me over the course of my career is that the best um uh treatment for colon cancer is to prevent it from occurring in the first place. And so screening uh uh is something that I would encourage everybody to think about and discuss with their healthcare provider. Obviously, with colon cancer, there is a barrier to screening. It involves either having somebody look in your colon with a colonoscopy or handling your own bowel movements, which most people don't really want to do. There are blood tests uh that are on the horizon that are showing a lot of promise. I would anticipate that probably within the next few years, we're going to have a blood test to look for early signs of colon cancer. And I think that has the promise to revolutionize colon cancer screening. Uh getting a blood draw is pretty routine for most people who who are engaged with the healthcare system. And I think that if we can get to the point where where blood testing uh becomes a viable option, I think it will really change the game for colon cancer screening.

SPEAKER_03: 33:26

Trevor Burrus, Jr. Could you address the embarrassment factor of colonoscopy? People are coming in to see you. They don't know who you are, they don't know who any of these folks are. They've been uncomfortably on the toilet all night long, and then they and then they have to put their tukas out there in the world, and and and it's uh it's embarrassing. How do you help people get over that?

SPEAKER_02: 33:45

It's it's actually one of the biggest challenges, I think, with with my practice, and it's one of the most difficult things to teach the fellows and trainees that we have uh here at Hennepin, which is that you're you're meeting someone usually for the first time, and within about five minutes, you have to convince them that they can trust you to put something up their bottom. That's not a situation that you're likely to be in any other time in your life.

SPEAKER_03: 34:11

I'm so glad that you're teaching the next generation of doctors that how important that point is.

SPEAKER_02: 34:16

Aaron Powell It's it it is a very um challenging art to build that trust in a very short period of time. And the reason for the time pressure is is you want to devote as much time to the actual exam as possible. Uh, you know, so there the the establishment of trust, the establishment of that rapport beforehand is certainly important, uh, but you don't want to spend so much time that you're limiting the time that you can spend on the exam, which is where the actual protection comes in.

SPEAKER_03: 34:42

Okay.

SPEAKER_02: 34:43

If you could leave us with one thought, what would it be? Get screened for colon cancer. Um and again, I I as a gastroneurologist, I am tremendously biased towards colonoscopy as a preferred screening modality, but that is really not the most important thing. The most important thing is that you get screened. I guess the other thing I would offer you is that if you do get screened and you do find that you have polyps, or hopefully not, but if you do find you have a colon cancer, consider telling your relatives. Uh you know, as we discussed, family history uh is an important uh risk factor in colorectal cancer. And so if you care about the people that you're related to, letting them know uh so that they can adjust their their needs uh appropriately would be would be the kind thing to do.

SPEAKER_03: 35:30

Such important information. Jake, you've been a guest with me on a number of my media appearances, including this podcast more than once. Thanks so much for being here once again.

SPEAKER_02: 35:38

It's great fun, David.

SPEAKER_03: 35:39

I'm glad to do it. Okay, listeners, that's the advice from the show. Make sure you get screened. And if you do have an abnormality, consider telling your relatives so they too can get screened. Thank you for listening. I hope you picked up some good information. We'll be back in two weeks' time for another episode. And in the meantime, be healthy and be well.

SPEAKER_01: 35:58

Thanks for listening to the Healthy Matters Podcast with Dr. David Hilden. To find out more about the Healthy Matters Podcast or browse the archive, visit healthymatters.org. Got a question or a comment for the show? Email us at healthymatters at hmed.org or call 612-873-TALK. There's also a link in the show notes. The Healthy Matters Podcast is made possible by Hennepin Healthcare in Minneapolis, Minnesota, and engineered and produced by John Lucas at Highball. Executive producers are Jonathan Camito and Christine Hill. Please remember we can only give general medical advice during this program, and every case is unique. We urge you to consult with your physician if you have a more serious or pressing health concern. Until next time, be healthy and be well.