Cancer Care Connections

A Gastroenterologist’s Guide to Colon Cancer Screening

• Virginia Oncology Associates • Season 2 • Episode 20

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One of the most powerful tools in cancer prevention is sitting right in front of us, yet many of us delay using it. Dr. Edwin Lee, gastroenterologist with Capital Digestive Care, joins us to demystify colon cancer screening and explain why catching this disease early changes everything. 
 
Dr. Lee takes us through the critical importance of colon cancer screening and the significant guideline change that now recommends starting at age 45 instead of 50. This adjustment wasn't arbitrary – it's already saving lives by catching dangerous polyps in younger patients before they develop into cancer.  
The conversation demystifies the screening process, comparing stool-based testing options with colonoscopy, which Dr. Lee describes as a "two-in-one" procedure that both detects and removes potential threats. He walks us through what happens during a colonoscopy, how doctors measure their effectiveness through adenoma detection rates, and why family history might mean you need screening much earlier than you think.  
 
For those hesitant about screening, Dr. Lee offers reassurance that modern procedures are much more comfortable than in the past. With improved preparation solutions and effective anesthesia, there's no reason to postpone this potentially life-saving test. Whether you're approaching 45, have a family history of colon cancer, or simply want to be proactive about your health, this episode provides the information you need to take that crucial step. Don't let fear or inconvenience stand in the way of this life-saving screening - schedule your appointment today. 

Resources mentioned in this episode:

Thank you for listening! If you're interested in hearing more from Virginia Oncology Associates, make sure to subscribe to Cancer Care Connections on Apple Podcasts, Spotify, or anywhere podcasts are available, or listen online at cancercareconnections.buzzsprout.com.

Cancer Care Connections is the official podcast of Virginia Oncology Associates. For more information, visit us at VirginiaCancer.com. or find us on Facebook or Instagram at Virginia Oncology Associates.

INTRO: 0:07
Welcome to Cancer Care Connections. On this episode, Cheryl spoke with Dr. Edwin Lee, a gastroenterologist with Capital Digestive Care. Dr. Lee emphasizes the importance of colon cancer screening and explains why national guidelines changed in 2021 to lower the age of screening recommendations. He will provide insight into the modern methods of colon cancer screening options, while still advocating for colonoscopy, as this option provides a two-for-one approach to preventing colon cancer.

Cheryl: 0:43
Dr. Edwin Lee is a gastroenterologist with Capital Digestive Care in Suffolk. He moved to Hampton Roads in 2021 following a fellowship in gastroenterology at the University of Rochester in New York. Today, he'll be talking about the importance of colon cancer screening, a topic we really can't talk enough about. Dr. Lee, thank you so much for joining us today.

Dr. Lee: 1:04
Thank you for having me, Cheryl.

Cheryl: 1:05
I would love to start by getting an idea of what brought you into medicine, and gastroenterology in particular.

Dr. Lee: 1:14
Those are great questions. I think my personal commitment and motivation came from home, my brother. He was born with a large port wine stain, and there was always this wish to help people that I developed early on, and when I was in my first year of medical school, my uncle had, unfortunately, liver cancer, which made me get interested in gastroenterology and hepatology. And here I am.

Cheryl: 1:42
Yeah, and I think, as people are hearing this, as people are listening to your story, they can feel your passion, that you have a personal connection to wanting to find a solution, and I think that's really, really important. So, thank you so much for sharing that with us.

Dr. Lee: 1:59
Oh, thank you. It is something that I do on a daily basis, but I understand that sometimes it might be taboo for some people. It might be something you might not get to know in detail, and that's why I think this opportunity to talk more about it will be a really important thing that we'll do today.

Cheryl: 2:17
And I think that's so important that you mentioned as well is that people don't talk enough about certain topics, and we're talking about screening here, especially when we're talking about colon cancer screening. There are all kinds of medical screenings that people can take, but this one, people really don't talk too much about. Can you talk about why colon cancer screening in particular is so important?

Dr. Lee: 2:41
Those are great questions. I think. Currently, colon cancer ranks fourth in the cancers overall, and not only that, it is the second cancer that unfortunately kills the most, and the Preventive Services Task Force has come up with the grading system from "A" to different letters, "A" being the strongest, and colon cancer screening is one of the only two they consider a grade "A". That makes a huge difference in our lives. I think the cervical cancer screening would be the other category "A", and that's how important it is. Considering everything we do, it makes a big impact not only on the individual basis of our lives, but also on a population basis.

Cheryl: 3:35
And, as you are saying that, I think we should probably put a point on that. You said "A", like it is top of the line, when it talks about a screening that is super important, correct, that's what colon cancer gets. So I think, as we are talking about the guidelines for colon cancer, I think we should probably talk about age. When should people be thinking about that? We have people who are listening, who are cancer patients, family, friends, and medical professionals. At what age should we think about this?

Dr. Lee: 4:10
So, classically, we have all known the age of 50. And I think that has been known to all of us. But as of 2021, most of the societies have agreed upon decreasing the age to 45. And that was because they saw how colon cancer was one of the few cancers that were still increasing, especially in the age group between 40 and 49. And that's when they did the whole analysis between the cost, the benefits, and the risks. It was decided that yes, we need to start doing screenings earlier, at the age of 45, because that makes a huge difference in all of us.

Cheryl: 4:52
Right, and so you see that in your practice as well? You've been here since 2021, and that's when the rollback happened, so people thought they had until 50, and now it's 45.

Dr. Lee: 5:05
Right.

Cheryl: 5:08
Have you been able to see the difference with this earlier screening? 

Dr. Lee: 5:10
Absolutely, absolutely. We see patients who thankfully come, they are aware of the new guidelines. They come at the age of 45. And in my work, we do screening colonoscopies, and we sometimes find very large polyps that, if they had waited until the age of 50, could have become something dangerous. So that has had a large impact with the change. And we are very thankful that there has been, overall in the medical society, as well as in the media, a lot of information about the decrease in age to 45. And we're seeing more and more younger patients coming and getting at the appropriate age.

Cheryl: 5:48
Okay, I think we have to talk about the screening itself, because that is one of the reasons why people are waiting. They are procrastinating, they don't want it. But I was at the gym this morning, and actually, one of my friends, her husband, actually just got a colonoscopy and was talking about it. She talked about how uncomfortable it was for him. I think we have to really discuss more about the screening itself, the colonoscopy, and what goes into this, and why people are avoiding it, and why they shouldn't. So, doctor, could you just talk more about that particular screening?

Dr. Lee: 6:24
I think the two most common modalities that we see our patients get their colon cancer screening completed are either through stool testing or through colonoscopy, and of course, both of them have pros and cons for whichever method you choose. Both are very effective. The stool testing you can either do a fecal immunochemistry test (FIT) yearly, which is just the presence of detecting blood, but also they have an augmented test, where they also do some DNA analysis, and now there's a new company trying to do some RNA analysis in that stool.

Dr. Lee: 7:02
You've probably heard some of the brands out there, such as Cologuard. And those, when you do the combined FIT testing that we talked about with the DNA analysis, they say that you can do every three years, so you're able to get a few more years, and it's a very effective way to detect colon cancer. I think the biggest benefit is that it's convenient, you can do it from your home. It's just getting your stool sample and sending it over. But I think the colonoscopy, and probably I'm a little biased, but if you do a colon cancer screening through a colonoscopy, yes, you have to take a day off from work to go and do the colonoscopy and, yes, the prep can be sometimes really uncomfortable because we are not used to taking a medicine or a liquid that will make us go to the bathroom so many times.

Cheryl: 7:55
Right right.

Dr. Lee: 7:56
However, it is a two-in-one kind of a procedure, so you're able to not only do the screening but if you see a polyp, if you see something that is worrisome, you can right there, complete what we call a polypectomy, where we go and remove the polyp that could potentially grow into cancer.

Dr. Lee: 8:08
So you are able to accomplish two things in one procedure. In the stool testing that we talked about a few minutes before, if it is positive, you still need to go for the colonoscopy. The issues that are sometimes not spoken about are also economical. Colon cancer screening is covered by most insurances, but once you do a stool testing and it is positive, you then have to go for the colonoscopy. It's not a screening anymore, but a diagnostic test. Because you had a positive stool testing, sometimes the insurance companies might cover less of that. So I think that is an important piece that sometimes we don't know as well when we're choosing to go for A or B.

Cheryl: 9:00
Right, that is an important thing to note. One other thing you mentioned a few minutes ago was when you had younger patients, the 45-year-olds, getting that testing, you could go in there and take care of any potential problems that could have gotten bigger in the future. I think that's an important thing to say. Could you talk more about that?

Dr. Lee: 9:22
Absolutely.

Dr. Lee: 9:23
There's a metric, and I know it is not something that is commonly known out there, but there's a metric called ADR.

Dr. Lee: 9:31
It stands for adenoma detection rate (ADR), and adenoma is a type of polyp that has the potential to become cancerous. We gastroenterologists get judged, actually, by our ADRs. If you don't meet a certain ADR, they put you on a remediation, meaning you have to get more training. It is about 30%; 30% for male patients and 20% for female patients, and that means that out of the 10 colonoscopies that you're doing for colon cancer screening, in at least three of those patients, you should be finding a precancerous polyp. If you're not finding precancerous polyps for at least three patients, it means you are not doing as good of a job trying to find those precancerous polyps. That is very important because each ADR that you increase has been shown to decrease colon cancer. Let's say, from 30% you actually went to 31%. That 1% you gain in ADR has been shown to decrease colon cancer in 3%. So it is the test that is having us find those polyps, remove them earlier so they're not developing into cancer later on.

Cheryl: 10:40
I mean, really, you can hear as you're discussing the numbers that this is truly preventative. It's catching something early enough before it becomes a bigger issue.

Dr. Lee: 10:51
Right. That is the goal of the colonoscopy, and you know, not only the colonoscopy but also the stool testing is trying to find early on so it doesn't become a larger problem in the future.

Cheryl: 11:04
I want to talk about some risk factors for colon cancer. So we've talked about the age now for when screening should happen is 45, but are there cases when it should happen even earlier, and what should people be looking out for?

Dr. Lee: 11:20
That's a great question. If you have a family member, especially a first-degree relative, meaning parents, siblings, children, if any of them had any dangerous polyps or colon cancer, that might qualify you to get colonoscopies much earlier. So, one of the strongest predictors and risk factors is actually family history. We say that it's either the age of 40 or 10 years prior to your family member. So, if you had a sibling who had a very dangerous and large polyp at the age of 48, you might actually need to get your colonoscopy at the age of 38. However, if somebody had at age of 58, then 40 would be kind of the default. So it's whatever comes first, age 40 or 10 years prior to your family member.

Dr. Lee: 12:07
So, genetic factors are probably the largest risk factor. There are other risk factors, such as having a sedentary lifestyle. If you're not exercising on a regular basis, if you either smoke or drink alcohol regularly, it might be a risk factor. And recent studies have shown that eating processed meat, especially the nitrates in processed meat, might increase your risk factors quite a bit.

Cheryl: 12:33
Well, you answered my question there. I was going to ask about how you can decrease any of those risk factors outside of genetics, and you mentioned that. Are there any others that maybe we should think about as we're trying to live a healthier life?

Dr. Lee: 12:49
Those are the main ones: exercising regularly and avoiding common vices such as smoking and alcohol consumption, and decreasing the consumption of processed meat. Those are important things that you could do that will decrease your chances of developing colon cancer.

Cheryl: 13:06
As far as how someone would come about getting these tests. Is it something that you go through with your primary care? Do they call your office? How does that work with getting the screening itself?

Dr. Lee: 13:21
That's an important question. I believe that we are very lucky to have great primary care physicians in the Tidewater area, and they're very good and diligent about having their patients complete one form of colon cancer screening. But even for patients who don't currently have an established primary care physician and are interested because either they have a family history or because they're at the age where they need to start doing the colon cancer screening, you can reach out directly to your local gastroenterologist. I know our office and our company offer direct access to colonoscopy as well. It doesn't have to be related to your primary care physician, but that is usually the way patients get referred to us.

Cheryl: 14:03
I'm glad you said that, though, because people might have different ways as far as they're getting their medical care, and it's not always a straight path, but if they had questions, they could call your office.

Dr. Lee: 14:16
Absolutely.

Cheryl: 14:17
As far as treatment, I'd love to hear more about that. Kind of going past the screening to what happens if it is, in fact, colon cancer. Could you talk about some ways of treatment and maybe some new technology that you've heard of that can support a patient who is dealing with colon cancer?

Dr. Lee: 14:35
Absolutely. I think we are in a current era where the new technology is coming on very fast, and it has been helping all of us, I think, for the treatment of colon cancer. Usually, it centers around a multi-modality kind of treatment. So gastroenterologists, colorectal surgeons, and oncologists are all on board together. The colorectal surgeons will be planning the surgical side; they have robots so they're able to perform surgeries with a precision that was not even possible before, especially near the rectum, where the physical space is much narrower.

Dr. Lee: 15:16
The surgeons are able to do much more in that sense, and with the oncology team, they have not only the traditional chemotherapies but they have immunotherapies and other therapies to help our patients. So usually if you hear that the diagnosis of the colon cancer was made, there's a staging system where usually you want to do what we call a cross-sectional imaging. So, you want to do a CAT scan, you want to see if the colon cancer is localized versus if there is another organ that could have potential cancer cells, and depending on those factors our team will decide if the best approach is to start with surgery and then have a chemotherapy later on, or sometimes start with the chemotherapy first and then do the surgery later. There are different technical terms. They will say adjuvant therapy versus neoadjuvant therapy, and I think our oncologists will be able to better explain those treatments. But there are different things that we do, and we do them as a team.

Cheryl: 16:20
At that point, if someone is listening to this and wants to get more information about screenings for colon cancer itself, where would you direct them to go?

Dr. Lee: 16:30
I think there are several good websites out there you can get your information from: The American College of Gastroenterology is one of our main societies in gastroenterology. You'll be able to find a lot of information there. And our company, Capital Digestive Care, also has information that our patients can go and access.

Cheryl: 16:53
Dr. Lee, anything else you'd like to add? Anything you'd like to say to patients, families, or anyone listening? Anything you'd like to share with them before we say goodbye?

Dr. Lee: 17:01
For many years, there was a taboo about colon cancer screening. A lot of our patients would be scared. You know what my experience would be? Will I have pain? What is the process of doing the prep? And sometimes they would postpone because of those fears of not knowing what's going to happen. And I just wanted to say that we now have better preps. They're not as hard as the ones we had in the past. We have good anesthesia providers to help our patients go through the procedure so that they won't feel any pain or they won't have discomfort. So it is a process that has been very smooth, and they should try to get more information and try to get their colonoscopies done and get their colon cancer screenings, as this makes a big difference in all of our lives.

Cheryl: 17:53
Dr. Lee, thank you so much for your time. We appreciate it.

Dr. Lee: 17:56
Thank you. Thank you for your time.

EXIT: 18:03
Thank you for joining us today on Cancer Care Connections. We explored how colon cancer screening can save lives. While colon cancer may be the second-deadliest cancer, it is highly detectable and preventable. Through the use of colon cancer screening, with modern procedures, improved preparation solutions, and effective anesthesia, a colonoscopy is much more comfortable than many anticipate. Remember, a colonoscopy is not the only option. Talk to your doctor to see if a stool test may be right for you. Don't postpone this crucial screening if you are of age or have a family history. Schedule your appointment today. 

Don't forget to subscribe to our podcast via Apple Podcasts, Spotify, or anywhere podcasts are available, or listen online at cancercareconnections.buzzsprout.com. Cancer Care Connections is the official podcast of Virginia Oncology Associates. For more information, visit us at VirginiaCancer.com or find us on Facebook or Instagram at Virginia Oncology Associates.