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While colonoscopy is the gold standard of colorectal cancer screenings, it's certainly not the only method to detect this disease. Cleveland Clinic Florida gastroenterologist Brenda Jimenez, MD, joins Butts & Guts to discuss how flexible sigmoidoscopies, FIT tests, and other screenings compare to a colonoscopy.

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Which Colorectal Cancer Screening Method is Right for You?

Podcast Transcript

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

Hi, everybody, and welcome again to another episode of Butts & Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery at the Cleveland Clinic here in beautiful Cleveland, Ohio.

Today we're going to talk a little bit about which colorectal cancer screening method is right for you, and I'm very pleased to have Dr. Brenda Jimenez, who's a gastroenterologist at one of our partner institutions, Cleveland Clinic Florida’s Weston Hospital. Dr. Jimenez, thank you so much for joining us on Butts & Guts.

Dr. Brenda Jimenez: Thank you for having me.

Dr. Scott Steele: Yeah, absolutely. For those of our listeners, we always like to set up with tell us a little bit about yourself. Where are you from? Where did you train? How did it get to the point that you're working here at the Cleveland Clinic?

Dr.Brenda Jimenez: I'm from the Dominican Republic, originally. I did my residency in Boston. After four years of very cold weather, I decided to move to sunny Florida. So I did my gastroenterology fellowship training here at Cleveland Clinic, and I just love the environment here, and I've been here for more than 10 years, actually.

Dr. Scott Steele: Fantastic. Represent the DR. I love it.

We'll go with a little bit, kind of a big, broad view. You don't have to get too much into the weeds, but just for our listeners, how does colorectal cancer start? I know there's a lot of different pathways, but in general, how does it progress?

Dr. Brenda Jimenez: It usually begins as a non-cancerous growth. It's called a polyp and they develop over many years. It's on the inner lining of the colon. Anywhere between 10 to 20 years is how long it takes to develop.

Like you mentioned, there's different pathways. Adenomas are the most common type of precancerous polyp, and about a third to a half of all individuals will eventually develop one or more of these pre-cancerous growths.

Dr. Scott Steele: What are some of the symptoms and warning signs of colorectal cancer that our patients and listeners out there should not ignore?

Dr. Brenda Jimenez: First of all, early colorectal cancer has no symptoms, but when it starts to develop more advanced, things that we shouldn't ignore include rectal bleeding, any type of blood in your stool, black stools, or bright red blood, a temporary change in your bowel movements, especially in the shape of the stool, you could spin like a pencil or any pain with a bowel movement or frequent cramping in your lower belly.

Dr. Scott Steele: Let's say that you're somebody out there that doesn't have any one of those symptoms. You're stone cold normal, and you're rolling along. Colorectal cancer screening is still important, so what percentage of U.S. adults qualify for screening that are up-to-date on their screening? Is it a large percentage, or are we missing out on a lot of patients that should get screened that aren't doing it?

Dr. Brenda Jimenez: We're certainly missing out quite a bit and it varies by age group. The goal is to have 80% of the population that should be screened to be screened. Currently, only about 60% of the population of that is that qualifies for screening is being screened, and this decreases by age group. I know we'll talk about this maybe shortly, but the screening recommendations maybe have changed a little bit. So in the greater than 45 age group, roughly about 50% and anywhere between 45 to 49, it's only 21%. So we're far, far away from the goal that we would like of 80% of screening.

Dr. Scott Steele: Before we delve into the methods of screening, can you tell me a little bit about the difference between a screening examination and a diagnostic examination?

Dr. Brenda Jimenez: That really means if you have no symptoms and we're doing the test just to find either an early colorectal cancer or a polyp, so that's a screen test. Once you have some symptoms, just like what we mentioned earlier, any change in your bowel habits, abdominal pain or rectal bleeding, that would be considered a diagnostic test because we're looking for something, trying to find a reason for your symptoms.

Dr. Scott Steele: Okay. We're going to walk through some of the different screening options and tell us a little bit about, is there something, one factor more than another, or it does it matter what we do why you would recommend one or the other? So, first, colonoscopy. What is it and when is it useful and how does that differ from other methods?

Dr. Brenda Jimenez: Like you mentioned, there's different types of screening. The colonoscopy is considered both diagnostic and therapeutic because it can not only detect a polyp or a pre-cancerous growth or a cancer, but we can also treat at the same time and removing that. So they're offering the screening for everybody. We just offer different options. If you have availability of a colonoscopy, I would definitely recommend that for you because it's a one-step test. Whereas the other tests that we'll talk about a little bit later, there are two steps. In other words, if they are positive, then a colonoscopy would be recommended to try to, number one, identify why it was positive and provide treatment, or the next step in the management.

Dr. Scott Steele: What's the difference between a colonoscopy and a flexible sigmoidoscopy?

Dr. Brenda Jimenez: A colonoscopy evaluates the entire colon, whereas a flexible sigmoidoscopy only evaluates the left side of the colon. Flexible sigmoidoscopy does require some sort of preparation as well. Usually you need a specialized or a trained physician to perform it. In addition, some patients request anesthesia. And if you have a precancerous growth on the left side, a second step test, like a colonoscopy, would be recommended as well. So it's not being performed as often for screening for colorectal cancer.

Dr. Scott Steele: How about some of these tests that kind of fall under the fecal occult blood tests or the fecal immunochemical test, the FIT test?

Dr. Brenda Jimenez: These are stool-based tests, just like you mentioned, and the FIT test looks for any type of hidden blood in the stool. It detects early cancer and also an advanced or a colon polyp that's a little bit bigger in size. If it's positive, so then a colonoscopy is recommended, and it's something that is usually recommended to be done on a yearly basis.

There's other stool-based tests that in addition to the FIT test, or the fecal immunochemical test, and they look for abnormal DNA. That one is called a stool DNA, or that can detect that there's also hidden blood. But in addition to that, it looks for abnormal DNA, and this one is recommended every three years.

The benefits of these are these are tests that you can do at home. You don't need to do a special prep or a special diet, and you don't need to go to a physician, take time off of work to get these tests done. So there are some... It's possible that more patients will be able to do these tests.

Dr. Scott Steele: I know a lot of patients ask me, "I don't want to take that prep. I don't want to go through that. So, can I just get a virtual colonoscopy?" What's a virtual colonoscopy and do you have to have a prep for that?

Dr. Brenda Jimenez: You do. That's definitely one question we get asked quite often, and you don't need anesthesia, but other than that, it's very similar to a colonoscopy in that you have to clean out the colon. Even though it is a virtual colonoscopy, it's an imaging test. If there is stool covering or coating the colon, the radiologist won't be able to see it. Even though they do something called stool tagging, they won't really be able to see. In addition to that, you have to inflate the colon as well, so there's some discomfort with that. And if a polyp is seen, then a colonoscopy may also be advised to follow up on that polyp.

Dr. Scott Steele: We're going to go into a segment I like to call Truth or Myth. What is real and what is not. Truth or Myth: some of these tests are better than others at identifying colorectal cancer.

Dr. Brenda Jimenez: That is the truth. Colonoscopy, it has a higher ability to detect colon cancer and colon polyps, anywhere between 60 close to 70%. the other tests are a little bit lower, anywhere between maybe 40 to 70% with a stool-based DNA test, but they're not one is better than the other.

Dr. Scott Steele: Truth or Myth: a patient should talk with their primary care doctor first before scheduling any screening tests.

Dr. Brenda Jimenez: That is true. You should definitely speak with your primary care doctor. They'll go over the different options, making sure that there are some tests that are safe for you to do. If there are any specific risk factors within your family, some tests maybe more recommended as opposed to others, if there was any family history, for example.

Dr. Scott Steele: Truth or Myth: if my first screening, using any one of the methods we talked about before, shows no concerning follow-ups, I don't need to schedule another one unless I start developing symptoms.

Dr. Brenda Jimenez: I would consider that a myth, and I think that most physicians would agree with that. The risk of colon cancer increases with age. So even though there's a negative test at age 45 or age 50, for example, that doesn't mean you won't have another polyp within another 10 years. It does take some time for these to grow, so I would say that's a myth.

Dr. Scott Steele: I know you touched base a little bit on this before, but can you just briefly recap what are those tests that you talk about do we need to have a prep on, and which ones do not have to?

Dr. Brenda Jimenez: Colonoscopy, which is actually visualizing the colon, needs a preparation to clean out the colon and we'll be able to see the lining, see if there's any polyps.

The flexible sigmoidoscopy, again because it's a visual test, needs to have some sort of clean out. The difference in the colonoscopy basically, usually we sometimes use an enema.

Then for the CT colonography or the virtual colonoscopy, that also requires a preparation.

Dr. Scott Steele: You had mentioned a little bit earlier about there was some recent changes specifically regarding screening tests so for asymptomatic average risk patients. Can you talk about what those were and what does it mean to be average risk?

Dr. Brenda Jimenez: Average risk means there is no family history of colon cancer in your family, usually first-degree relatives or multiple secondary-degree relatives, and that the age of diagnosis is also very important. Younger patients, less than 60, will increase your risk of colon cancer. There are some patients that, if they have some underlying conditions like inflammatory bowel disease, they are also at a higher risk.

Average risk patients means no family history, no symptoms. Up until quite recently, the recommendations were to begin screening at age 50, and over the past years, decade that the risk of colon cancer in that age group greater than 50 had been decreasing. However, we have seen a rise in incidence of colorectal cancer in those less than 50. It actually has doubled in the population between 20 to 49. So that's led over the past two to three years the recommendations to start screening at an earlier age, and that age is 45.

Dr. Scott Steele: That's fantastic stuff. We like to get to know our guests a little bit better, so we'd like to wind up with some quick hitters. So for you, number one, what is your favorite food?

Dr. Brenda Jimenez: Favorite food has to be Italian, pasta.

Dr. Scott Steele: Number two, what is your favorite sport either to watch or to play?

Dr. Brenda Jimenez: Baseball, Dominican and Boston Red Sox.

Dr. Scott Steele: Ooh, yeah. Then third, what is the last nonmedical book that you've read?

Dr. Brenda Jimenez: It is Abraham Lincoln and the Path to Abolition (The Crooked Path to Abolition: Abraham Lincoln and the Antislavery Constitution).

Dr. Scott Steele: Then, finally, I normally ask my Cleveland question, but since you're a guest from down south, I'll ask you a little bit, to our listeners, what is a reason that they should schedule their next vacation to the Dominican Republic?

Dr. Brenda Jimenez: Ooh. It has to be the warm waters and the beach and clear, clear beaches, clear blue. You can see are your toes, your feet. It's amazing.

Dr. Scott Steele: And just by happenstance, my brother-in-law and my niece and my nephew are there right now, and I had no idea going into this interview, so fantastic.

So, for our final take-home message for our listeners regarding this concept of screening for colorectal cancer?

Dr. Brenda Jimenez: Know your options. Know that colonoscopy is not your only option. There's many different screening options, and the best screening test is the one that gets done. So speak with your physician, and make sure you get screened at an appropriate time.

Dr. Scott Steele: Fantastic words of advice. To learn more about colorectal cancer or to schedule a colonoscopy in the Florida region, please visit clevelandclinicflorida.org/colonoscopy or clevelandclinicflorida.org/coloncancer. That's clevelandclinicflorida.org/colonoscopy or clevelandclinicflorida.org/coloncancer.

If you're closer to Ohio, please visit clevelandclinic.org/colonoscopy. That's clevelandclinic.org/colonoscopy.

Finally, remember in times like these, it's important for you and your family to continue to receive medical care. And be rest assured at every Cleveland Clinic location, we're taking all the necessary precautions to sterilize our facilities and protect our patients and caregivers. Dr. Jimenez, thanks so much for joining us on Butts & Guts.

Dr. Brenda Jimenez: Thank you so much. Have a great day.

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

Butts & Guts
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Butts & Guts

A Cleveland Clinic podcast exploring your digestive and surgical health from end to end. You’ll learn how to have the best digestive health possible from your gall bladder to your liver and more from our host, Colorectal Surgery Chairman Scott Steele, MD.
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