What All Adults Should Know About Colorectal Cancer with Dr. David Liska

Podcast Transcript

Note: As of May 2021 the recommended age for a colonoscopy is now 45.

Deanna Pogorelc:

Welcome to the Health Essentials podcast, brought to you by Cleveland Clinic. I'm your host, Deanna Pogorelc. Now, March is Colorectal Cancer Awareness Month. You might not know that colorectal cancer is the second leading cause of cancer deaths in the US. In recent years, it's become increasingly more common in younger adults, but it's actually very preventable and curable if it's detected early. So here to tell us everything we need to know about risk factors, who should get screened, and what symptoms we should never ignore, is Dr. David Liska. He's a Colorectal Surgeon and Director of the Sanford R. Weiss Center for Hereditary Colorectal Cancer, and also the Center for Young-Onset Colorectal Cancer, here at Cleveland Clinic. Hi, Dr. Liska, thanks so much for being here.

Dr. David Liska:

Yeah, Thanks so much for having me.

Deanna Pogorelc:

Listeners, please remember that this is for informational purposes only, and is not intended to replace your own physician's advice. Dr. Liska, can you start by telling us a little bit about colorectal cancer here in the US? What impact does it have? Are the number of cases going upward or downward?

Dr. David Liska:

Yes, colorectal cancer is a major problem in the US, and in most of the world. In the US, it is the third most common cancer among men and women, and just like you said, it's the second most common cause of cancer-related deaths. Each year, approximately 150,000 people are diagnosed with colorectal cancer. In terms of the trends of the numbers, so overall the numbers are improving, and this is directly related to the uptake of screening for colorectal cancer here in the United States, and over the last five years, the rate has dropped by about 1% each year. However, just like you said, the opposite is the case for people under the age of 50, where the rate has been increasing by about 2% each year for the last five years, and alarmingly, if this trend were to continue, we would expect over the next 10 years the incidence of colon cancer in young adults to double, and rectal cancer to quadruple.

Deanna Pogorelc:

Do we know why that is happening or what things might be contributing to that?

Dr. David Liska:

Yeah, that is a great and unfortunately, still unanswered question, and we and many others are doing a lot of research on that. So we know that hereditary colorectal cancer syndromes are more commonly found in young people with colorectal cancer. However, the majority of young people with colorectal cancer do not have a hereditary condition, and there are several possible explanations as to why colorectal cancer is increasing in the young.

              So one theory that makes a lot of sense looks at the parallel obesity epidemic here in the United States, and we know that obesity and a sedentary lifestyle are risk factors for colorectal cancers, and so are diets that are associated with obesity. So it makes a lot of sense to say that one of the reasons for the rise in young onset colorectal cancer is due to the rise of obesity in the United States. However, that being said, obesity, diet, and exercise, are clearly not the only explanation for colorectal cancer in the young. Many of my own young patients with colorectal cancer are actually quite fit and eat a healthy diet. So there's certainly more work that we need to do to understand why colorectal cancer in the young is happening more and more commonly.

Deanna Pogorelc:

And when we talk about colorectal cancer, is this the same thing as colon cancer? I want to talk a little bit about the terminology and make sure we understand what specific parts of the body are we talking about?

Dr. David Liska:

Right, that's a great question. So the colon and rectum make up the large intestine, and the first part of the large intestine is the colon. So the small intestine meets the colon at the cecum, that's the first part of the colon, and then as the food gets absorbed and water gets absorbed in the colon then, and becomes stool and enters the rectum, which is the last half foot or so of large intestine, and then exits through the anus. So that's what the colon and rectum are, and the reason why we differentiate between colon and rectal cancer is because treatment can be different for the two.

Deanna Pogorelc:

But a cancer can develop on any part of that that you just mentioned?

Dr. David Liska:

Correct, correct. Yeah, exactly. Cancer can develop in any part of the colon or rectum, and interestingly, what we've found for specifically when talking about young onset colorectal cancer, is that the majority of these cancers are on the more distal aspect of the large intestine, meaning much more commonly in the rectum or the last part of the large intestine.

Deanna Pogorelc:

Okay. So can we start by talking a little bit about prevention? What kind of things should we be doing every day to take care of our colon and prevent this type of cancer?

Dr. David Liska:

Right. So, so really the most important thing about preventing colorectal cancer is getting screened, and that's obviously not something that you do every day, but that's something that's part of our healthcare maintenance, and that's something that needs to be part of everybody's routine, is getting regular screening examinations. In terms of other things that you can do every day in terms of lifestyle issues, so it's been shown that diets that are rich in fruits, vegetables, and whole grains can protect from colorectal cancer, and calcium and vitamin D are some of the minerals and supplements that people have found can help protect from colorectal cancer. Regular exercise can also be protective, avoiding anything that can lead to obesity, and not smoking. Smoking is a big risk factor for colorectal cancer, and alcohol also, an excessive intake of alcohol are all risk factors for colorectal cancer. So again, a healthy diet and avoiding smoking and alcohol are some of the major things that people can do to protect themselves,

Deanna Pogorelc:

You mentioned earlier genetics, and I was wondering if somebody in your family has colorectal cancer, does that mean that you are also at increased risk?

Dr. David Liska:

Yeah, absolutely, and that's a really important part, another thing that people can do to help prevent colorectal cancer, and that's knowing their family history. This is not a topic that a lot of people talk about openly, but it is important for everyone to know what their specific family history is in terms of, especially their parents and siblings, if they had colon cancer, or even if there wasn't a colon cancer but just an advanced precancerous polyp, all those would increase one's own risk for colorectal cancer, and would often also change when and how often you should start to have screening examinations done. So it's important for everyone to know their family history and it's a good thing for families to discuss openly, because it has important implications for everyone. So, yes, it's important to know your family history and then discuss that with your physician, because like I said, it might affect when you should start to be screened and how often.

Deanna Pogorelc:

Absolutely. Okay, and what about our own health history? If we have a history of another digestive condition, like maybe IBS, or inflammatory bowel disease, does that play any role in our risk?

Dr. David Liska:

Absolutely. So besides the known genetic hereditary colorectal cancer conditions which really increase your risk, intestinal diseases such as inflammatory bowel disease, which includes Crohn's disease or ulcerative colitis, has been shown to increase the risk of colorectal cancer. Irritable bowel syndrome, so IBS, which is different from IBD, has not really been directly linked to colorectal cancer. However, ulcerative colitis or Crohn's colitis, which often can be mistaken initially for IBS, due to the increase in information, has been directly linked to an increased risk for colorectal cancer, and again, patients who have one of these conditions and have it for a long time, are at higher risk and need to have more frequent screening performed. Other diseases that have been shown to increase the risk, not to the same extent, would be diabetes, which is also becoming more and more common in the United States, so that's another disease that can increase the risk of colorectal cancer to some extent.

Deanna Pogorelc:

Can you help us understand how colorectal cancer starts? How does it develop, and how long does that take?

Dr. David Liska:

Yeah, so that's been studied quite a bit, and we have a fairly good understanding of how colorectal cancer happens, and it's really due to the large intestine changing its lining very frequently, almost on a weekly basis does the entire lining of the large intestine get exchanged, and due to the high turnover cells in the large intestine, mutations can happen, and these mutations, if they provide a survival benefit to that cell, can then cause a polyp to form. A polyp can then get larger and develop more mutations, which eventually leads to cancer. So it's a slow process that can take many years, and it really gives us a chance to catch the cancer before it turns into a cancer, at the precancerous stage when it's still a polyp, and that's why colonoscopies can help prevent colorectal cancer, because it can find the polyp before it turns into a cancer, and can be removed.

Deanna Pogorelc:

Great. So let's talk a little more about colonoscopies. Who should be getting them, when should they start, and how often should they be getting them?

Dr. David Liska:

Right. So for many years now, the general screening recommendation has been to start screening at the age of 50, and this is certainly still true. However, due to the rise in young onset colorectal cancer that we just discussed, and more recently in 2018, the American Cancer Society changed their recommendation to start screening at age 45. And importantly, the US Preventive Services Task Force recently also published draft recommendations that they're in the process of finalizing, to start screening at age 45 for all average risk individuals, and once these recommendations are finalized, most insurances will start covering screening colonoscopies at age 45.

Deanna Pogorelc:

Is it still safe for people to be getting colonoscopies during the pandemic?

Dr. David Liska:

Yes, absolutely, and it's still important. This pandemic has now been going on for almost a year, and this is a long time to skip screening colonoscopies, and we have seen at the beginning of the pandemic, there was a significant drop in the number of people who came for their colonoscopies. And I myself have seen some patients who delayed their colonoscopies, and then presented with a cancer that was potentially more advanced than if they had had a colonoscopy when they were supposed to have it. So definitely, screening is still important even during this pandemic. We and many other health institutions have many policies in place to make sure that when people come for the screening colonoscopy, that it is performed safely, and make sure that people can have what's important for their health, even during this pandemic. Besides colonoscopies, there are other screening methods available that people can do from home, which would not require coming to the hospital, and those are some of those stool-based tests that we've discussed, and again, if those are positive, they would then require a colonoscopy, which is still safe even during the pandemic, and important to do.

Deanna Pogorelc:

Okay, so when we talk about colonoscopies, we have to talk a little bit about the prep. I know this is something that can be intimidating for some folks, as well as anesthesia during the procedure. How do you make decisions about what method of prep to recommend to your patients, and is that something they can discuss with you if they're concerned?

Dr. David Liska:

Absolutely, yeah. Preparation and how the anesthesia should be performed in the colonoscopy can definitely be individualized based on the patient's needs. The most common type of preparation is something based on polyethylene glycol, where you usually drink half a gallon to a gallon clear liquid, and that ends up cleaning out the colon. However, some patients don't tolerate this, partially due to the amount, due to the flavor. So there are different types of prep available, and more recently, there are some other preparations available that are much smaller in [inaudible 00:13:04]. They're not always covered by insurance, however, they can make the process a lot easier. So again, if a patient has a hard time finishing a large amount or gets nauseous from a specific preparation, the type of preparation can be changed.

              Also, we very often now recommend our patients to do a split preparation, where they do half of it the night before and half of it the morning of, which also makes it a little bit easier on the patient and actually makes the cleanout more effective. So these are some of the methods and some of the options available to patients in terms of preparation. It's definitely not fun, but there are alternatives available that can make it a little easier, and every patient is different in terms of how they're going to respond to preparation, and some patients, especially those who have a history of chronic constipation, will sometimes need a more extensive prep, and that's also an important thing to bring up with your doctor.

              Now, in terms of the anesthesia for colonoscopies, there's different types of anesthesia available, different types of sedation, and some patients, pretty rare, will ask for no sedation at all, and they want to be awake and talking throughout the entire procedure. And that is an option, however, you want to talk to your endoscopist beforehand, to make sure that they are aware that you would like to do that. The most common form of sedation that we do here is called conscious sedation or moderate sedation, where we use medications that sedate the patient and also control pain. And most patients with those medications are asleep for the entire procedure, but can be aroused by shaking them or talking to them loudly.

              Patients who have a hard time with that specific type of sedation have an option for anesthesia where they're completely asleep during the procedure and don't notice anything. For those, you usually need an anesthesiologist present, so it's not a standard approach, but it's definitely available for patients who have had a hard time during previous colonoscopies, or who know ahead of time that they wouldn't want to be awake for any of it, or not even just lightly asleep.

Deanna Pogorelc:

Great. That's great to know. So what happens if a polyp is discovered during someone's colonoscopy? What happens then?

Dr. David Liska:

Right. So when we find a polyp during the colonoscopy, which is really the point of the colonoscopy, to see if there are any polyps so we can remove them, the polyp gets removed, and there are different methods of removing these polyps, depending on the size and where they're located. But generally, in the vast majority of cases, the polyp can be completely removed and then sent to the pathologist, who will look at it under the microscope and then tell us what type of polyp it is.

              And just to let everyone know, it's very common to find small precancerous polyps during a colonoscopy. That's not something to be alarmed about after the colonoscopy, if you are told that you've had a polyp. In fact, probably 40% of men and a little lower percentage of women will have a polyp found during their colonoscopy. And like I said, those have been examined in the lab, and the most common precancerous polyp is called a tubular adenoma and, when that is found, they will inform you when your next colonoscopy should be performed. Depending on the type, the size, and number of polyps, they will then have your endoscopist reach out to you to tell you when you should have your next colonoscopy.

Deanna Pogorelc:

Great. And if for some reason someone decides they don't want to have a colonoscopy, are there other alternative ways that you can screen for colorectal cancer?

Dr. David Liska:

Absolutely, yeah, and a colonoscopy is just one method of screening. There are several different methods of screening, and they can be grouped under two different categories. One is a visual inspection of the colon, and that's the most common one, is the colonoscopy, but there's a virtual colonoscopy, which is done as a CT scan that can also be quite sensitive in visualizing small [inaudible 00:17:04] cancers. There's a flexible sigmoidoscopy, which examines only the last part of the large intestine, and those are the sort of the three main exams that visualize the colon.

              There are other screening examinations that are based on stool, and one of them is the FIT test, which looks for blood components in the stool. Another one that's becoming more and more popular looks at DNA within the stool with a combination of blood products, and that's the Cologuard brand that we've seen a lot of advertisements for recently. And all these tests are effective in screening for colon cancer, but they're different when compared to the colonoscopy, where a colonoscopy can find early polyps and remove them, whereas the stool-based test, if they come back abnormal, would then still require a colonoscopy to intervene upon and confirm.

Deanna Pogorelc:

Okay, great. So you mentioned earlier that the increase in screening is helping reduce colorectal cancer. And I'm curious, how often is it discovered that way, in screening versus someone developing symptoms, and coming in that way?

Dr. David Liska:

Yeah, that's a great question that I don't think we really know the answer for here in the United States. The good news is that more and more people are getting screened, but unfortunately, it's still not 100% of the people who should be getting screened. And so, unfortunately it's still a large proportion of patients when they're diagnosed with colorectal cancer, are diagnosed due to symptoms, and unfortunately, once you're diagnosed with colorectal cancer due to symptoms, it often is at a more advanced stage than if it's caught with screening. So ideally, we would be able to catch all colorectal cancers with screening, rather than due to symptoms. However, in young people with colorectal cancer, where many of them don't have a recommendation for a screening, it is much more common to be caught due to symptoms.

Deanna Pogorelc:

So when we talk about symptoms, what are some of the warning signs that people should be aware of that they should never ignore?

Dr. David Liska:

Right. So one of the important warning signs is any blood in your stool or blood coming from your rectum, and while that's often attributed to hemorrhoids, which is very often true, it should not be just attributed to hemorrhoids without a discussion with your physician, and possible examination. So whenever somebody sees blood in their stool or on their toilet paper, you should definitely bring it up with your physician and discuss if a colonoscopy or other examination is necessary.

              Second, another common symptom is change in bowel habits, and that can be a variety of things. It depends on what a person's normal bowel habits are. So if a person has one bowel movement a day, and then all of a sudden goes to not having a bowel movement for many days, and this is something that's consistent over a period of time, that's definitely something to bring up with your physician. Or the opposite, if you have one bowel movement a day, and then you go to having diarrhea and going 10 times a day, and again, it's not just a one-time thing after that Mexican meal you had somewhere, but something that's consistent with you for many days, that's definitely something to bring up with your physician.

              Another thing to look out for is a change in the caliber of your stool. If you consistently note that the caliber of your stool is smaller and different from what it usually looks like, that's another thing to bring up with your physician. Other more vague symptoms that could be related to colorectal cancer would be unintentional weight loss. So if you notice that you're losing weight and you don't really have a reason for it, despite you think you're eating normally, that's something to bring up with your physician.

              Abdominal pain is not a very common symptom related to colorectal cancer, but it can be. So if you have abdominal pain, that's again, consistent over a period of time, that's something to bring up with your physician as well. And sometimes it can be even more vague and nondescript, where you just feel tired and have no energy for a long period of time, and that can sometimes be due to anemia, meaning a loss of blood that's not detected and it slowly reduces your blood count, and that can cause fatigue. So all those are symptoms that can be associated with colorectal cancer, and should definitely be discussed with your physician.

Deanna Pogorelc:

And then is the first step there to see your primary care physician?

Dr. David Liska:

Yes, definitely your primary care physician is always a good place to start, but it can also be directly with a gastroenterologist or colorectal surgeon, and depending on how easy your access is to your primary care physician, usually it makes sense to start with somebody, a physician who knows you, but there are specialists available as well.

Deanna Pogorelc:

Well, what have we seen in terms of outcomes for these younger adults who are developing colorectal cancer, when it's caught early?

Dr. David Liska:

Right, so colorectal cancer when caught early, in the vast majority of cases, can be cured. Unfortunately, we have seen in younger people there's a higher percentage of people who are young who present at a more advanced stage, and at that point, the cancer can be a little harder to cure. Still, the majority of patients, even in the more advanced stage, as long as it hasn't spread to other organs, in most cases, the cancer can be cured. So that's really the first thing to focus on when facing a diagnosis of colorectal cancer, that there are very effective treatments available, and that most patients will be able to be cured.

Deanna Pogorelc:

Yeah. Can you just give us an idea of some of those treatments that you mentioned, what could someone expect in terms of that?

Dr. David Liska:

Right. So the mainstay of treatment for colorectal cancer is surgery, where the part of the colon that has the cancer in it is removed. Following that surgery, once we know the exact stage of the cancer, there's a discussion with the oncologist if chemotherapy is needed or beneficial. For most localized and early cancer, chemotherapy is not necessary, and when it's more advanced, when it has spread to lymph nodes or other organs, usually chemotherapy will be recommended.

Deanna Pogorelc:

So this has been great, this has been so helpful. If you had to give one takeaway message for our listeners, especially our younger listeners, what would you say would be the takeaway for them?

Dr. David Liska:

Right. So number one is listen to your body, listen to the symptoms that your body's is telling you that are happening, number two is know your family history, and number three, have an open communication with your primary care doctor and any other physician you see, to make sure that you tell them about your risk factors and about any symptoms you might develop.

Deanna Pogorelc:

Great. Well, thank you so much for being here today. And if you'd like to learn more about Cleveland Clinic's Digestive Disease Institute, or schedule an appointment, visit clevelandclinic.org/colonoscopy. To listen to more podcasts with our Cleveland Clinic experts, please visit clevelandclinic.org/hepodcast, or subscribe wherever you're listening now. You can always follow us at Cleveland Clinic on Facebook, Twitter, and Instagram for more health tips, news, and information. Thanks for tuning in.