Colorectal Cancer Symptoms and Screening Guidelines

Podcast Transcript

Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Hi again everybody, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. Very happy to have on a guest that we've had on the past, Dr. Sarah Vogler, who is our Vice Chair of Operations here in the Department of Colorectal Surgery at the Cleveland Clinic, and also our Section Chief for Pelvic Floor Disorders. Sarah, welcome back to Butts and Guts.

Sarah Vogler: Thanks.

Scott Steele: So for those who don't know, March is Colorectal Cancer Awareness Month. And colorectal cancer, as you know, is one of the leading causes of cancer deaths in the United States, in between two and three each year. However, the unique thing about colorectal cancer is that we have advances in early detection and treatment make it one of the most preventable and potentially treatable forms of cancer. So we are extremely excited to have you on, and thank you so much for joining us here on Butts and Guts.

And so, as you know, I'd like to always go back for those who are listening to the back issues of our podcast. Tell us a little bit about yourself, where you're from, where'd you train and how to come to the point that you're here?

Sarah Vogler: So I was born and raised actually in Ohio, Cincinnati. I did my colorectal surgery training in Minnesota, just like you. And then I've been at Cleveland Clinic for almost two years now. As Section Head for Pelvic Floor Disorders program, but also here at main campus, working with all the other sections.

Scott Steele: So, let's go very high level on colorectal cancer. So how does colorectal cancer start and kind of what time periods are we started with, does it take three days or what, what, what does it do.

Sarah Vogler: So you don't wake up in the morning and think, I think I have colorectal cancer today. It can be somewhat insidious, which is why we recommend screening with colonoscopy because it typically starts as a very benign polyp. So those in the colon that over years not hours can develop into something bigger, a bigger polyp, and then eventually turn into something that's malignant cancer.

Scott Steele: So Sarah, we know that there is a lot of patients out there that may have had a colonoscopy and worked completely surprised by cancer diagnosis, that they are completely asymptomatic and would have never thought. That's one of the reasons why we were talking about this here today. But just in general, what are some of the symptoms and maybe some of the warning signs of colorectal cancer that we're telling our patients out there do not ignore this, go in and get checked out.

Sarah Vogler: So definitely don't ignore things that are somewhat obvious. Like a change in bowel habits, they could be blown off pretty easily by, they eat something, or my stomach hasn't been acting normal. But any change in bowel habits, blood in your stool, unusual aches or feelings of bloating discomfort that are persistent, and don't go away and say within 24 hours, you should talk to a physician about that. Don't try to just treat it yourself.

Scott Steele: So I, let me this maybe a little bit different way. So a lot of the symptoms you just talked about, whether it be pain or bleeding or changes about habits that could be symptoms due to benign disease, right? And so some are obviously in the majority of time, it's less serious than others. So how do you know, how do we tell our patients when they should actually talk to a doctor?

Sarah Vogler: So that's the tricky thing. So, and you probably see this too, that our whole clinic sometimes can say hemorrhoids, hemorrhoids, hemorrhoids. Everybody can stay at hemorrhoids because these are very non-specific symptoms of the bleeding and changes in bowel habits or GI symptoms. So if it's a persistent symptom that has gone on for, I don't know, say two to three weeks, but it's certainly unusual to you is when you should seek some medical advice. And certainly at you are in the age category of above 45 or 50 in a screen timeframe, we should be having a screening colonoscopy. You should definitely seek medical attention and probably a colonoscopy.

Scott Steele: Yeah, I'm going to get in a little bit of that later. So yeah, a lot of patients may ask us. So I have a hand in some of these symptoms, I'm a little bit nervous about it. I don't want to go and tell them anybody, but so it's that first step to see a primary care doctor or when they go from there?

Sarah Vogler: I think probably the first step, the easiest step would be to see your primary care physician. They know you best. So they probably know, are you on blood thinners or is there something else that is causing these symptoms more likely in you. And they can start some easy treatments or evaluations and then they will refer you on if they think it's time to do something like a colonoscopy or other colorectal cancer screening methods.

Scott Steele: So one of the more common questions we get is let's take just the average person out there. When should the average person, not a lot of risk factors and no risk factors, when should they get their first colonoscopy?

Sarah Vogler: So the easy answer is at age 50, some of the changes that are underway are moving that to an earlier age. So you may have heard that it's a popular cancer now in younger people. So maybe not in the 70 to 80 year olds, but it's more than 40 to 50 year olds. So the American Cancer Society in 2018 made recommendations to start screening average risk individual individuals at age 45, as opposed to 50. And the U.S. Preventative Task Force is currently in the process of finalizing a recommendation to start screening at age 45. Note: as of May 2021 this recommendation is official - anyone age 45 and older should get a screening colonoscopy.

Scott Steele: Yeah, absolutely. And I think it's important to know that maybe something that didn't get a lot of highlights is actually African-Americans and those patients who have metabolic syndrome, we would commonly think of them as more than the old East patients. The screening recommendations a few years ago dropped at 45. So I think that's the major change that we're seeing out there. So you mentioned it very briefly. I'm going to circle back and make you discuss that a little bit more. It's the part about the terms screening colonoscopy. There's something else, something that patients may have heard of that diagnostic poll. And is in a diagnostic colonoscopy in general, isn't as at the same thing?

Sarah Vogler: The act or procedure it's going to be done is identical. The reason it's called something different is diagnostic means that patient has a symptom. So they're presenting with bleeding or pain or change in bowel habits. And you're doing the colonoscopy to seek a diagnosis for that symptom. Screening colonoscopy is simply meant for a healthy individual with absolutely no symptoms that we're just going to make sure there's not a cancer or a polyp or something else that could be taken care of in a preventative version.

Scott Steele: So we're going to enter into the session of the podcast that I like to call Truth or Myth. So Truth or Myth: If I have a family history of colorectal cancer, or I have inflammatory bowel disease, such as Crohn's or ulcerative colitis, I should be getting a colonoscopy before the age of 50.

Sarah Vogler: True. Well, it depends, I guess. So if your family member had colon cancer before the age of 60, then your first colonoscopy would be 10 years before. So it would be before you're at age 50. Absolutely. Everybody should have a colonoscopy at least by age 50.

Scott Steele: Yeah, so I think a good way to think about that is, again, we're talking about screening colonoscopies. We just mentioned a little bit about the changing guidelines. That is a process of evolution. I think everybody should be aware of. And I think that now the important point is, is what we're really talking about is a risk factor. So understand your family history, understand that there's certain things that may make you more prone to having a higher risk of the development of colorectal cancer.

Truth or Myth: If my first colonoscopy shows no concerning polyps at all, I don't need to schedule another colonoscopy unless I started developing symptoms.

Sarah Vogler: Myth. Although, that seems to be a popular thing that people think. So you need to have a colonoscopy at least every 10 years, if you're at age 40, normal colonoscopies, which means that you do not have any polyps,

Scott Steele: How does the role of the cleanliness of the bowel for when we follow those patients back? I know that obviously one of the worst things that patients do and we'll get into the prep here just a minute, but does that play a role in terms of when we bring patients back?

Sarah Vogler: Yeah. So if your bowel prep is not clean enough, that you would be able to see polyps of a certain size. So typically it's like six millimeters. If you're not going to be able to find a polyp that's about that size, because there's too much stool or murkiness in the colon, then you should not wait 10 years. You're going to have to come back probably about two years. It depends on the situation and the patient's history, but your endoscopy, this will make that recall faster than 10 years.

Scott Steele: So Truth or Myth: colon cancer is different than the rectal cancer.

Sarah Vogler: Both are cancers, but they're not the same. So rectal cancer is in the very end of the GI tract and the last 18 centimeters of the GI tract, right before the anus and colon cancer is throughout the rest of the colon. They're treated slightly differently.

Scott Steele: Yeah. I encourage all of our listeners out there. We've had podcasts in the fact that talk about everything ranging from radiation therapy and chemotherapy for rectal cancer versus surgery followed by maybe, or maybe not chemotherapy. And we do have a lot of good data type podcasts that are dedicated to that. So please see some of those back podcasts so that you can kind of go into that difference right there.

Sarah Vogler: Okay, one for you,Truth or Myth: the prep is worse than the scope.

Scott Steele: So I would say this as somebody who practice what they preach. I had gotten a colonoscopy and I will tell you that the prep itself wasn't as bad as what I thought it was, but definitely the scope was no big deal at all. I barely remember the scope I can tell you. So for all of you who are worried about the scope and what it going to mean, alleviate that concern from my lips to your ears. Speaking of that, can you talk a little bit about the different methods to prep for a colonoscopy?

Sarah Vogler: So most of the preps involve patients being on mostly liquid diet that they prior to the procedure, but the actual prep, meaning what you drink to clean out your colon can vary. So it may be as simple as Gatorade and MiraLax at a certain dose, or it may be something that's prescribed, go lightly, don't know all the different ones on the market right now, but your physician will pick which prep is safest for you and the one they have the best results in cleaning out.

Scott Steele: So for those who have had some discussions or maybe seen some TV advertisements, there's obviously some other screening tests that are available for the detection of colorectal cancer. Can you just touch very high-level on what those may be and then what the halfway name lead down, depending on what the show?

Sarah Vogler: So ideally you want to screen by some method, for sure. You don't want to ignore this. But the advantage to colonoscopy versus Cologuard or some of the DNA screenings it is that a colonoscopy will actually allow for identification of a polyp and then removal of it as well. So you would eliminate your risk of that turning into a cancer. The other screening techniques are more likely just going to identify you shouldn't have a full [inaudible] because there might be something there.

Scott Steele: So in general, whether it's being scared of the prep or serving the scope or any different plethora of reasons that may be out there for our listeners to say I am not going to get one of those is this something that patients can discuss with their doctor?

Sarah Vogler: Absolutely. They definitely should discuss it with their doctor. And I think the majority you've probably had this experience, the majority of patients say afterwards, Oh, that was no big deal. And I'm so relieved that now I know I'm cancer free and I'm good for 10 years.

Scott Steele: That's fantastic. And so Sarah, as you know, we always like to end up with guests, a couple of quick hitters. And since you've been on before, I thought I would give you a couple of different questions.

And so what if you were to fill in this blank, if you had all the money in the world, I would go to this place on a trip. What would that place be?

Sarah Vogler: The French Riviera .

Scott Steele: Okay, any back stories on that?

Sarah Vogler: It's absolutely gorgeous.

Scott Steele: Fantastic. And so if we were to walk into your operating room and listen to the music, if any, what would we be listening to?

Sarah Vogler: Country.

Scott Steele: Any particular artists in general?

Sarah Vogler: Kenny Chesney, probably.

Scott Steele: Okay. I like it a lot. And so your first car that you ever had?

Sarah Vogler: It's a really ugly blue Oldsmobile.

Scott Steele: Fantastic. And then final quick hitter, you know, we talk a lot about this, especially during COVID where a lot of this idea of just looking at a television series, and this is the one you need to be able to see if you have any recommendations for our listeners.

Sarah Vogler: I think I go through Netflix too much now, so I'm watching Homeland. But it's hard to pick one that I would live or die by.

Scott Steele: While I think Homeland would be a nice, nice recommendation for those of you out there. So final take home message to our listeners just regarding colorectal cancer symptoms and screening guidelines in general.

Sarah Vogler: I think it's important to take care of yourself. And this is an easy way to keep yourself healthy and actually keep your whole family healthy by knowing everybody's risks because they can impact your family given that it has some genetic predisposition. So make sure you're staying safe and getting your colonoscopies at age 50.

Scott Steele: That's fantastic advice. And so to learn more about colorectal cancer, to schedule a colonoscopy, please visit clevelandclinic.org/colonoscopy. That's clevelandclinic.org/colonoscopy, or call the Digestive Disease and Surgery Institute at 216.444.7000. That's 216.444.7000.

And again, you've heard me say this before, but please remember that in times like these, especially as we're talking about screening type procedures that may be completely symptomatic, or if you're having those symptoms that you don't want to tell anybody about. It is absolutely important for both you and your family to continue to receive medical care. Rest assured here at the Cleveland Clinic, we're taking all the necessary precautions to sterilize our facilities, protect our patients and our caregivers.

Dr. Vogler, thanks so much for joining us on Butts and Guts.

Sarah Vogler: Thanks a lot!

Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.