Feb. 9, 2026
Colon Cancer Screening
Gastroenterologist Dr. Sith Sekar joins Navin Kumar to review the important topic of colon cancer screening, including how to calculate individual risk based on family history, options for screening, and some tips to ensure high-quality colonoscopy.
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[SPEAKER_00]: Welcome back to Run the List.
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[SPEAKER_00]: Today we will be discussing a very high-yield topic for primary care and one we know very well in the field of GI and that is colon cancer screening.
00:09.863 --> 00:17.532
[SPEAKER_00]: We are joined by Dr. Sith Saker, who is a general gastroenterologist at the Brigham Women's Hospital and who has a particular interest in medical education.
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[SPEAKER_00]: Sith, thank you so much for joining us today.
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[SPEAKER_01]: Thanks Nevin, it's an honor to be on the Run the List podcast and to help teach about this very important topic today with you.
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[SPEAKER_00]: Same here, Sith, so let's go ahead and run the list.
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[SPEAKER_00]: Let's start by setting the stage in primary care clinic.
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[SPEAKER_00]: You are seeing a 40-year-old healthy male with no past medical history.
00:37.158 --> 00:46.532
[SPEAKER_00]: As you are obtaining a family history, he mentions he had a paternal grandfather who passed away from colon cancer in his 80s and he believes his mother had a colon pop removed recently as well.
00:47.132 --> 00:51.739
[SPEAKER_00]: He asked if he needs to start colon cancer screening at an earlier age because of this family history.
00:52.394 --> 00:57.578
[SPEAKER_00]: Sith, how do you think about estimating risks for colon cancer in the context of family history?
00:57.760 --> 00:58.481
[SPEAKER_01]: It's a great question.
00:58.541 --> 01:03.205
[SPEAKER_01]: When I think about family history, I think it's really important to think in the first degree relatives.
01:03.225 --> 01:04.586
[SPEAKER_01]: That's what's really important.
01:04.626 --> 01:16.237
[SPEAKER_01]: So any first degree relative with colon cancer at any age, then you would begin colonoscopy screening at age 40 or 10 years before the earliest colon cancer diagnosis.
01:16.657 --> 01:27.767
[SPEAKER_01]: The other thing that's important is to sort of figure out polypistry in your family and ideally obtain procedural and pathology reports of the family member, especially if there's concern
01:27.747 --> 01:45.469
[SPEAKER_01]: You're particularly concerned about any polyp that's greater than one centimeter in size that has two bill of villacistology or villacistology, high-grade dysplasia or any advanced cell serrated lesions, and then in that case you would think of it in the same way that you would as colon cancer.
01:45.449 --> 01:59.155
[SPEAKER_01]: and begin screening at age 40 or 10 years before the diagnosis, so you always think about advanced polyps as the famous colon cancer and in both those cases you would start at age 40 or 10 years before the diagnosis.
01:59.827 --> 02:01.849
[SPEAKER_00]: Some said, those are such important points.
02:01.910 --> 02:04.272
[SPEAKER_00]: It's so critical to get a detailed family history.
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[SPEAKER_00]: And to remember, not just ask about colon cancer, but also advanced polyps.
02:09.218 --> 02:19.551
[SPEAKER_00]: And when you are discussing the advanced polyps, I like how you broke it down between advanced at anomalies, polyps, and advanced SESIL polyps, as well, because there are two different types of precancerous polyps.
02:20.072 --> 02:27.741
[SPEAKER_00]: And both of those, if they have those characteristics that you said, will constitute an advanced polyp and also a positive family history.
02:27.721 --> 02:40.832
[SPEAKER_00]: So in this case, let's say the patient finds out that his mother had just a small and an omelette, say it was like three millimeters that was removed so below that one centimeter threshold and no other first degree relatives of colon cancer or advanced polyps.
02:41.393 --> 02:45.342
[SPEAKER_00]: So based on this information, when would you recommend he start colon cancer screening?
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[SPEAKER_01]: Yeah, so based on the current guidelines, he'd be considered an average risk for coal and cancer and should start screening at age 45.
02:54.315 --> 03:14.164
[SPEAKER_01]: But, you know, for example, if the mother, she had a three millimeter pallet, but if it was sort of 1.5 centimeters or had any of those advanced features and she was diagnosed with that pallet, but even age 35, then you would think about starting at 25 for him if it was diagnosed at 60, then you would think about starting at 40 for him.
03:14.583 --> 03:14.983
[SPEAKER_00]: Perfect.
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[SPEAKER_00]: So you basically just take the earliest time, whether it be age 40 or 10 years before the age of diagnosis, like you just went through.
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[SPEAKER_00]: All right.
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[SPEAKER_00]: So now that we discussed when to start screening, what are the options available to screen for colorectal cancer?
03:29.180 --> 03:30.582
[SPEAKER_01]: So there's there's a ton out there.
03:30.622 --> 03:36.709
[SPEAKER_01]: And when I think about counseling patients for colorectal cancer screening, I try to frame it around prevention and adherence.
03:36.689 --> 03:49.266
[SPEAKER_01]: And, like we discussed before, colorectal cancer typically develops either from adenomitis or serrated polyps over many years, which gives us a great window to either remove precancerous lesions or detect cancer early when outcomes are the best.
03:49.907 --> 04:04.367
[SPEAKER_01]: So for average risk adults, which is very important, so no prior history of polyps and no family history as we discussed prior, they're true broad-based screening strategies, either you can go with colonoscopy, direct visualization, or stool-based testing.
04:04.347 --> 04:10.877
[SPEAKER_01]: Both are guideline endorsed, neither is better than the other, and that effectiveness of either strategy depends heavily on patient adherence.
04:11.477 --> 04:22.153
[SPEAKER_01]: Colonoscis is the most comprehensive option, it visualizes the entire colon and allows for immediate palper removal, which is why it's considered both a screening and preventative test and one that we usually prefer.
04:22.173 --> 04:26.980
[SPEAKER_01]: A normal exam generally allows for tenure interval before the next one.
04:26.960 --> 04:35.714
[SPEAKER_01]: The trade-offs though are that you do need to go through that bowel preparation, need for sedation, a small but real risk of complication such as bleeding a perforation.
04:35.774 --> 04:37.597
[SPEAKER_01]: And I'll come perspective.
04:37.637 --> 04:42.445
[SPEAKER_01]: It offers a lowest risk of interval colorectal cancer when performed with good quality metrics.
04:42.746 --> 04:49.677
[SPEAKER_01]: The other big group are the stool-based tests such as fit testing or a cologard which is a multi-targeted stool DNA testing.
04:50.028 --> 04:54.212
[SPEAKER_01]: They're non-invasive and completed at home, which improves patients doing it.
04:54.252 --> 04:59.997
[SPEAKER_01]: These tests detect a colplode or abnormal DNA shed by the advance that it knows most are cancer.
05:00.518 --> 05:08.925
[SPEAKER_01]: Their key limitation is that they do not prevent the cancer or do they, and they do not remove any polyps, and they require strict adherence to repetesting a regular intervals.
05:09.646 --> 05:18.634
[SPEAKER_01]: But the most important point is that any positive stool-based test mandates a short interval diagnostic colonoscopy, and that's really important for patients to understand.
05:18.833 --> 05:24.211
[SPEAKER_00]: Seth, that was a really helpful overview of the available screen tests and the guidelines behind which tests to choose.
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[SPEAKER_00]: Are there any other screen tests that you use in certain patients or scenarios that we have not yet discussed?
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[SPEAKER_01]: Yeah, one that comes up from time to time is CT colonography.
05:33.460 --> 05:39.449
[SPEAKER_01]: It's actually most commonly used when a colonoscopy is incomplete or technically not feasible to do.
05:39.590 --> 05:49.785
[SPEAKER_01]: This can happen when there's a redundant or very torturous colon fixed regulations from prior surgeries or patient intolerance from sedation or from the procedure.
05:49.765 --> 05:54.110
[SPEAKER_01]: It provides a non-invasive cross-sectional evaluation of the entire colon.
05:54.171 --> 06:06.826
[SPEAKER_01]: It can identify clinically significant polyps, typically those that are greater than 5 millimeters, but unfortunately, it can't really identify any of those really flat lesions that SSL-serated polyps can be, or any polyps less than 5 millimeters.
06:07.367 --> 06:19.182
[SPEAKER_01]: The key limitations are that it still does require bowel preparation like a colonoscopy, but doesn't allow for biopsy or polyp removal, and any concerning finding still require follow-up colonoscopy.
06:19.162 --> 06:28.159
[SPEAKER_01]: In practice, its highest value is as a completion study after an incomplete colonoscopy to avoid any misproximalusions from where you can get past.
06:28.595 --> 06:49.303
[SPEAKER_00]: I think it's helpful just to review the bowel preparation since you've mentioned a few times both with obviously colonoscopy but as well as CT colonography and so in our institution in most other institutions this involves being on a clear liquid diet the day prior to the exam and then towards the later after noon to start the actual bowel preparation
06:49.283 --> 06:59.374
[SPEAKER_00]: Our standard is to use a Merrillax based preparation in which the patient takes a full bottle of Merrillax and mixes it in 64 ounces of clear fluid.
07:00.275 --> 07:15.952
[SPEAKER_00]: And we found that actually the split preparation where they then split the dose between doing 32 ounces of that prep that afternoon, and then the second 32 ounces five to six hours before the procedure leads to better visualization for the colonoscopy.
07:15.992 --> 07:18.615
[SPEAKER_00]: So it indeed is
07:18.595 --> 07:22.851
[SPEAKER_00]: It is a to-do for the patients to accomplish before they're examined.
07:23.312 --> 07:28.993
[SPEAKER_00]: So, can you comment about the importance of having a clean bowel preparation for the colonoscopy?
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[SPEAKER_01]: Yeah, it's paramount of importance.
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[SPEAKER_01]: It really sort of helps in making sure that there's no small polyps or lesions that are missed and it just sort of makes the whole procedure much more comfortable for the patient as less time is used sort of getting through the colon and it gives such a cleaner view while looking at the colon sort of on withdrawal and looking for polyps and
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[SPEAKER_01]: You know, unfortunately, if the preparation is not great, sometimes we have to repeat the colonoscopy in short interval or are not able to clear them for that full 10 years that we ideally like to if it's a normal colon.
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[SPEAKER_01]: So, it is sort of, you know, undertaking for the patient undergo right before the colonoscopy, it's so important to do it very carefully and well.
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[SPEAKER_00]: So, and I love how you touched on the quality metrics of a colonoscopy.
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[SPEAKER_00]: I think in addition to having an adequate bowel preparation, so much of this hinges on the endoscopy is taking their time when surveying the colon, looking in between folds.
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[SPEAKER_00]: And, uh, Sith, you can, you can comment on this, where are the most high risk lesions often missed during a colonoscopy and why do we pay special attention to that area of the colon?
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[SPEAKER_01]: Yeah, so there's a couple of places I really pay a careful attention through the colon because it's so easy to miss lesions or polyps.
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[SPEAKER_01]: There are one of them is right behind the aloeocycle valve right at the end of the colon sort of polyps can definitely be flat and sort of right behind there and on the right side or the ascending colon in the seacum, there's definitely a higher risk of having set soil, so right at lesions, which are sort of these flatter lesions that are much easier to miss.
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[SPEAKER_01]: And then the other big spot is right at the hepatic flexure right where that turn is made.
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[SPEAKER_01]: into the ascending colon just because it's sort of a blind spot as if you're driving it's sort of a blind spot on a colon hospice.
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[SPEAKER_01]: It's a really taking time looking at that area at least two to three times with careful withdrawal and then spending sort of adequate time withdrawing throughout the whole colon.
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[SPEAKER_01]: Our metrics are quality metrics are always sort of improving now.
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[SPEAKER_01]: We're trying to hit at least 10 minutes each 10 minutes on what's
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[SPEAKER_01]: That's really important because these lesions can be very small, they can be very flat and very easy to miss, so taking your time is really important during a colonoscopy.
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[SPEAKER_00]: That's great, Seth.
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[SPEAKER_00]: Yeah, when I have medical students come, shadow me and endoscopy, and I have them, shadow you as well.
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[SPEAKER_00]: I think they're always surprised by how small and subtle some of these pops are, so it truly takes an experienced eye, but just extra time to find these lesions that can otherwise be potentially missed, so.
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[SPEAKER_00]: This was great.
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[SPEAKER_00]: I want to get back to our case and let's review.
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[SPEAKER_00]: So based on your knowledge of the guidelines, you recommend that this patient start colon cancer screening at age 45 as he's considered average risk for CRC.
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[SPEAKER_00]: Together, you get a side-on plan for a screening colonoscopy at that time as he is a healthy candidate and he's motivated to undergo a diagnostic and potentially therapeutic procedure.
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[SPEAKER_00]: He also feels reassured by his average risk status after your review of the guidelines.
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[SPEAKER_00]: So with that, SIF, can you conclude our episode with some RTL pearls from today?
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[SPEAKER_01]: Absolutely.
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[SPEAKER_01]: I think the biggest pearl and one that's really important to understand is that it's important to learn your patient's family history, obtaining any patient's family's procedure and pathology or reports if needed.
10:37.012 --> 10:46.482
[SPEAKER_01]: A lot of times those advanced add-inomas can be missed in the patient's family history as it's not something often mentioned to children
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[SPEAKER_01]: Patients usually know their family history of, but those advanced how to know them as into review, anything that's greater than one centimeter in size, has two below villas or villas histology, high grade dysplasia, or any sort of advanced sesalcerated lesions are really important to know because that puts them at sort of the same risk as having colon cancer in their first degree relatives would and starting screening at age 40 or 10 years before the diagnosis.
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[SPEAKER_01]: That's a really important pearl to understand, and then there are a lot of different colon cancer screening strategies.
11:20.611 --> 11:31.150
[SPEAKER_01]: Colonoscopy provides both that screening and diagnostic aspect of removing the polyps and lesions at the time of the procedure, but understanding that the best strategies, the one that the patient is going to follow.
11:31.130 --> 11:34.815
[SPEAKER_01]: If they're reluctant to get a colonoscopy, but we'll undergo stool testing.
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[SPEAKER_01]: I think it's important to discuss that with them, talk between fit and DNA-based, such as coal guard, do it at the appropriate intervals, and most importantly, if it does become positive for them for that colonoscopy, so that we can do more of a diagnostic look to try to see why a term positive if there's a large polyp or anything like that, that needs to be removed.
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[SPEAKER_00]: Those are some great pearls, Sith, and you know, I do think the bow preparation is the most challenging piece of the experience for patients and when I have patients who come see me for the first time for their colon cancer screening and colonoscopy.
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[SPEAKER_00]: It's often that first step of just getting through the prep and then once they're actually here for the procedure, everything like you said, provided that it is done carefully and with high quality goes very smoothly almost all the time.
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[SPEAKER_00]: So the ability to screen for colon cancers is so, so important.
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[SPEAKER_00]: So I really appreciate you going through all the different options and especially that take home point that the best screening strategies, the one that you're patient is going to follow through with.
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[SPEAKER_00]: Thank you so much to this was great.
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[SPEAKER_00]: We had such a nice time discussing colon cancer screening in depth with you and I look forward to having you back on RTL in the future.
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[SPEAKER_01]: Thank you for having me.
00:00.031 --> 00:01.313
[SPEAKER_00]: Welcome back to Run the List.
00:01.633 --> 00:09.222
[SPEAKER_00]: Today we will be discussing a very high-yield topic for primary care and one we know very well in the field of GI and that is colon cancer screening.
00:09.863 --> 00:17.532
[SPEAKER_00]: We are joined by Dr. Sith Saker, who is a general gastroenterologist at the Brigham Women's Hospital and who has a particular interest in medical education.
00:18.053 --> 00:20.035
[SPEAKER_00]: Sith, thank you so much for joining us today.
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[SPEAKER_01]: Thanks Nevin, it's an honor to be on the Run the List podcast and to help teach about this very important topic today with you.
00:26.423 --> 00:29.407
[SPEAKER_00]: Same here, Sith, so let's go ahead and run the list.
00:30.208 --> 00:33.133
[SPEAKER_00]: Let's start by setting the stage in primary care clinic.
00:33.153 --> 00:36.597
[SPEAKER_00]: You are seeing a 40-year-old healthy male with no past medical history.
00:37.158 --> 00:46.532
[SPEAKER_00]: As you are obtaining a family history, he mentions he had a paternal grandfather who passed away from colon cancer in his 80s and he believes his mother had a colon pop removed recently as well.
00:47.132 --> 00:51.739
[SPEAKER_00]: He asked if he needs to start colon cancer screening at an earlier age because of this family history.
00:52.394 --> 00:57.578
[SPEAKER_00]: Sith, how do you think about estimating risks for colon cancer in the context of family history?
00:57.760 --> 00:58.481
[SPEAKER_01]: It's a great question.
00:58.541 --> 01:03.205
[SPEAKER_01]: When I think about family history, I think it's really important to think in the first degree relatives.
01:03.225 --> 01:04.586
[SPEAKER_01]: That's what's really important.
01:04.626 --> 01:16.237
[SPEAKER_01]: So any first degree relative with colon cancer at any age, then you would begin colonoscopy screening at age 40 or 10 years before the earliest colon cancer diagnosis.
01:16.657 --> 01:27.767
[SPEAKER_01]: The other thing that's important is to sort of figure out polypistry in your family and ideally obtain procedural and pathology reports of the family member, especially if there's concern
01:27.747 --> 01:45.469
[SPEAKER_01]: You're particularly concerned about any polyp that's greater than one centimeter in size that has two bill of villacistology or villacistology, high-grade dysplasia or any advanced cell serrated lesions, and then in that case you would think of it in the same way that you would as colon cancer.
01:45.449 --> 01:59.155
[SPEAKER_01]: and begin screening at age 40 or 10 years before the diagnosis, so you always think about advanced polyps as the famous colon cancer and in both those cases you would start at age 40 or 10 years before the diagnosis.
01:59.827 --> 02:01.849
[SPEAKER_00]: Some said, those are such important points.
02:01.910 --> 02:04.272
[SPEAKER_00]: It's so critical to get a detailed family history.
02:04.753 --> 02:09.078
[SPEAKER_00]: And to remember, not just ask about colon cancer, but also advanced polyps.
02:09.218 --> 02:19.551
[SPEAKER_00]: And when you are discussing the advanced polyps, I like how you broke it down between advanced at anomalies, polyps, and advanced SESIL polyps, as well, because there are two different types of precancerous polyps.
02:20.072 --> 02:27.741
[SPEAKER_00]: And both of those, if they have those characteristics that you said, will constitute an advanced polyp and also a positive family history.
02:27.721 --> 02:40.832
[SPEAKER_00]: So in this case, let's say the patient finds out that his mother had just a small and an omelette, say it was like three millimeters that was removed so below that one centimeter threshold and no other first degree relatives of colon cancer or advanced polyps.
02:41.393 --> 02:45.342
[SPEAKER_00]: So based on this information, when would you recommend he start colon cancer screening?
02:45.862 --> 02:52.993
[SPEAKER_01]: Yeah, so based on the current guidelines, he'd be considered an average risk for coal and cancer and should start screening at age 45.
02:54.315 --> 03:14.164
[SPEAKER_01]: But, you know, for example, if the mother, she had a three millimeter pallet, but if it was sort of 1.5 centimeters or had any of those advanced features and she was diagnosed with that pallet, but even age 35, then you would think about starting at 25 for him if it was diagnosed at 60, then you would think about starting at 40 for him.
03:14.583 --> 03:14.983
[SPEAKER_00]: Perfect.
03:15.003 --> 03:21.711
[SPEAKER_00]: So you basically just take the earliest time, whether it be age 40 or 10 years before the age of diagnosis, like you just went through.
03:21.992 --> 03:22.332
[SPEAKER_00]: All right.
03:22.813 --> 03:29.160
[SPEAKER_00]: So now that we discussed when to start screening, what are the options available to screen for colorectal cancer?
03:29.180 --> 03:30.582
[SPEAKER_01]: So there's there's a ton out there.
03:30.622 --> 03:36.709
[SPEAKER_01]: And when I think about counseling patients for colorectal cancer screening, I try to frame it around prevention and adherence.
03:36.689 --> 03:49.266
[SPEAKER_01]: And, like we discussed before, colorectal cancer typically develops either from adenomitis or serrated polyps over many years, which gives us a great window to either remove precancerous lesions or detect cancer early when outcomes are the best.
03:49.907 --> 04:04.367
[SPEAKER_01]: So for average risk adults, which is very important, so no prior history of polyps and no family history as we discussed prior, they're true broad-based screening strategies, either you can go with colonoscopy, direct visualization, or stool-based testing.
04:04.347 --> 04:10.877
[SPEAKER_01]: Both are guideline endorsed, neither is better than the other, and that effectiveness of either strategy depends heavily on patient adherence.
04:11.477 --> 04:22.153
[SPEAKER_01]: Colonoscis is the most comprehensive option, it visualizes the entire colon and allows for immediate palper removal, which is why it's considered both a screening and preventative test and one that we usually prefer.
04:22.173 --> 04:26.980
[SPEAKER_01]: A normal exam generally allows for tenure interval before the next one.
04:26.960 --> 04:35.714
[SPEAKER_01]: The trade-offs though are that you do need to go through that bowel preparation, need for sedation, a small but real risk of complication such as bleeding a perforation.
04:35.774 --> 04:37.597
[SPEAKER_01]: And I'll come perspective.
04:37.637 --> 04:42.445
[SPEAKER_01]: It offers a lowest risk of interval colorectal cancer when performed with good quality metrics.
04:42.746 --> 04:49.677
[SPEAKER_01]: The other big group are the stool-based tests such as fit testing or a cologard which is a multi-targeted stool DNA testing.
04:50.028 --> 04:54.212
[SPEAKER_01]: They're non-invasive and completed at home, which improves patients doing it.
04:54.252 --> 04:59.997
[SPEAKER_01]: These tests detect a colplode or abnormal DNA shed by the advance that it knows most are cancer.
05:00.518 --> 05:08.925
[SPEAKER_01]: Their key limitation is that they do not prevent the cancer or do they, and they do not remove any polyps, and they require strict adherence to repetesting a regular intervals.
05:09.646 --> 05:18.634
[SPEAKER_01]: But the most important point is that any positive stool-based test mandates a short interval diagnostic colonoscopy, and that's really important for patients to understand.
05:18.833 --> 05:24.211
[SPEAKER_00]: Seth, that was a really helpful overview of the available screen tests and the guidelines behind which tests to choose.
05:24.813 --> 05:29.890
[SPEAKER_00]: Are there any other screen tests that you use in certain patients or scenarios that we have not yet discussed?
05:30.055 --> 05:33.440
[SPEAKER_01]: Yeah, one that comes up from time to time is CT colonography.
05:33.460 --> 05:39.449
[SPEAKER_01]: It's actually most commonly used when a colonoscopy is incomplete or technically not feasible to do.
05:39.590 --> 05:49.785
[SPEAKER_01]: This can happen when there's a redundant or very torturous colon fixed regulations from prior surgeries or patient intolerance from sedation or from the procedure.
05:49.765 --> 05:54.110
[SPEAKER_01]: It provides a non-invasive cross-sectional evaluation of the entire colon.
05:54.171 --> 06:06.826
[SPEAKER_01]: It can identify clinically significant polyps, typically those that are greater than 5 millimeters, but unfortunately, it can't really identify any of those really flat lesions that SSL-serated polyps can be, or any polyps less than 5 millimeters.
06:07.367 --> 06:19.182
[SPEAKER_01]: The key limitations are that it still does require bowel preparation like a colonoscopy, but doesn't allow for biopsy or polyp removal, and any concerning finding still require follow-up colonoscopy.
06:19.162 --> 06:28.159
[SPEAKER_01]: In practice, its highest value is as a completion study after an incomplete colonoscopy to avoid any misproximalusions from where you can get past.
06:28.595 --> 06:49.303
[SPEAKER_00]: I think it's helpful just to review the bowel preparation since you've mentioned a few times both with obviously colonoscopy but as well as CT colonography and so in our institution in most other institutions this involves being on a clear liquid diet the day prior to the exam and then towards the later after noon to start the actual bowel preparation
06:49.283 --> 06:59.374
[SPEAKER_00]: Our standard is to use a Merrillax based preparation in which the patient takes a full bottle of Merrillax and mixes it in 64 ounces of clear fluid.
07:00.275 --> 07:15.952
[SPEAKER_00]: And we found that actually the split preparation where they then split the dose between doing 32 ounces of that prep that afternoon, and then the second 32 ounces five to six hours before the procedure leads to better visualization for the colonoscopy.
07:15.992 --> 07:18.615
[SPEAKER_00]: So it indeed is
07:18.595 --> 07:22.851
[SPEAKER_00]: It is a to-do for the patients to accomplish before they're examined.
07:23.312 --> 07:28.993
[SPEAKER_00]: So, can you comment about the importance of having a clean bowel preparation for the colonoscopy?
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[SPEAKER_01]: Yeah, it's paramount of importance.
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[SPEAKER_01]: It really sort of helps in making sure that there's no small polyps or lesions that are missed and it just sort of makes the whole procedure much more comfortable for the patient as less time is used sort of getting through the colon and it gives such a cleaner view while looking at the colon sort of on withdrawal and looking for polyps and
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[SPEAKER_01]: You know, unfortunately, if the preparation is not great, sometimes we have to repeat the colonoscopy in short interval or are not able to clear them for that full 10 years that we ideally like to if it's a normal colon.
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[SPEAKER_01]: So, it is sort of, you know, undertaking for the patient undergo right before the colonoscopy, it's so important to do it very carefully and well.
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[SPEAKER_00]: So, and I love how you touched on the quality metrics of a colonoscopy.
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[SPEAKER_00]: I think in addition to having an adequate bowel preparation, so much of this hinges on the endoscopy is taking their time when surveying the colon, looking in between folds.
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[SPEAKER_00]: And, uh, Sith, you can, you can comment on this, where are the most high risk lesions often missed during a colonoscopy and why do we pay special attention to that area of the colon?
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[SPEAKER_01]: Yeah, so there's a couple of places I really pay a careful attention through the colon because it's so easy to miss lesions or polyps.
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[SPEAKER_01]: There are one of them is right behind the aloeocycle valve right at the end of the colon sort of polyps can definitely be flat and sort of right behind there and on the right side or the ascending colon in the seacum, there's definitely a higher risk of having set soil, so right at lesions, which are sort of these flatter lesions that are much easier to miss.
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[SPEAKER_01]: And then the other big spot is right at the hepatic flexure right where that turn is made.
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[SPEAKER_01]: into the ascending colon just because it's sort of a blind spot as if you're driving it's sort of a blind spot on a colon hospice.
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[SPEAKER_01]: It's a really taking time looking at that area at least two to three times with careful withdrawal and then spending sort of adequate time withdrawing throughout the whole colon.
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[SPEAKER_01]: Our metrics are quality metrics are always sort of improving now.
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[SPEAKER_01]: We're trying to hit at least 10 minutes each 10 minutes on what's
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[SPEAKER_01]: That's really important because these lesions can be very small, they can be very flat and very easy to miss, so taking your time is really important during a colonoscopy.
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[SPEAKER_00]: That's great, Seth.
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[SPEAKER_00]: Yeah, when I have medical students come, shadow me and endoscopy, and I have them, shadow you as well.
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[SPEAKER_00]: I think they're always surprised by how small and subtle some of these pops are, so it truly takes an experienced eye, but just extra time to find these lesions that can otherwise be potentially missed, so.
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[SPEAKER_00]: This was great.
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[SPEAKER_00]: I want to get back to our case and let's review.
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[SPEAKER_00]: So based on your knowledge of the guidelines, you recommend that this patient start colon cancer screening at age 45 as he's considered average risk for CRC.
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[SPEAKER_00]: Together, you get a side-on plan for a screening colonoscopy at that time as he is a healthy candidate and he's motivated to undergo a diagnostic and potentially therapeutic procedure.
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[SPEAKER_00]: He also feels reassured by his average risk status after your review of the guidelines.
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[SPEAKER_00]: So with that, SIF, can you conclude our episode with some RTL pearls from today?
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[SPEAKER_01]: Absolutely.
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[SPEAKER_01]: I think the biggest pearl and one that's really important to understand is that it's important to learn your patient's family history, obtaining any patient's family's procedure and pathology or reports if needed.
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[SPEAKER_01]: A lot of times those advanced add-inomas can be missed in the patient's family history as it's not something often mentioned to children
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[SPEAKER_01]: Patients usually know their family history of, but those advanced how to know them as into review, anything that's greater than one centimeter in size, has two below villas or villas histology, high grade dysplasia, or any sort of advanced sesalcerated lesions are really important to know because that puts them at sort of the same risk as having colon cancer in their first degree relatives would and starting screening at age 40 or 10 years before the diagnosis.
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[SPEAKER_01]: That's a really important pearl to understand, and then there are a lot of different colon cancer screening strategies.
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[SPEAKER_01]: Colonoscopy provides both that screening and diagnostic aspect of removing the polyps and lesions at the time of the procedure, but understanding that the best strategies, the one that the patient is going to follow.
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[SPEAKER_01]: If they're reluctant to get a colonoscopy, but we'll undergo stool testing.
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[SPEAKER_01]: I think it's important to discuss that with them, talk between fit and DNA-based, such as coal guard, do it at the appropriate intervals, and most importantly, if it does become positive for them for that colonoscopy, so that we can do more of a diagnostic look to try to see why a term positive if there's a large polyp or anything like that, that needs to be removed.
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[SPEAKER_00]: Those are some great pearls, Sith, and you know, I do think the bow preparation is the most challenging piece of the experience for patients and when I have patients who come see me for the first time for their colon cancer screening and colonoscopy.
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[SPEAKER_00]: It's often that first step of just getting through the prep and then once they're actually here for the procedure, everything like you said, provided that it is done carefully and with high quality goes very smoothly almost all the time.
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[SPEAKER_00]: So the ability to screen for colon cancers is so, so important.
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[SPEAKER_00]: So I really appreciate you going through all the different options and especially that take home point that the best screening strategies, the one that you're patient is going to follow through with.
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[SPEAKER_00]: Thank you so much to this was great.
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[SPEAKER_00]: We had such a nice time discussing colon cancer screening in depth with you and I look forward to having you back on RTL in the future.
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[SPEAKER_01]: Thank you for having me.