Tanya Marie Balov D.O.

We find ourselves in the year 2023 and have come incredibly far in the realm of medical advancements – so why are we still drinking fluid that gives us diarrhea for a whole day? Why is the doctor still using that tube with a camera on the end of it for my colon cancer screening? Is there no better way?!

Well, here is the thing... there really isn’t. Colon cancer is the third most prevalent cancer in this country and colonoscopy still remains the gold standard for detecting these malignancies – so yes, we have to drink the stuff that makes us p**p our brains out as my toddler would love to say and yes, our gastroenterologist does have to use that small tube with the camera on the end of it to visualize our bowels. Are you uncomfortable yet? Good, you probably should be and that is ok! While it may not be the most glamorous topic to discuss, colonoscopies are essential for maintaining good health especially as we age. I know you may be thinking “a blog post about colonoscopies? Sounds like a pain in the butt.” Fear not dear reader, I will make this as painless as possible.

First, let’s break down exactly what a colonoscopy is before we move on. A colonoscopy consists of a long, flexible tube (colonoscope) that is inserted into the re**um to take a direct look at the colon (the longest part of your intestines). You will need to stick to a low fiber diet and drink a bowel cleansing solution that will have you running to the bathroom – but trust me it is worth it. Just think of it as a spa day for your colon. We can take a look at any abnormalities that may be present thanks to a very tiny camera at the end of that tube. If your specialist detects any abnormality, he or she may immediately perform a biopsy of that tissue and determine if there are precancerous polyps or cancer.

Now there are many other screening methods available including the cologuard (stool DNA test), FIT or FOBT testing (stool cards), virtual colonoscopy (using a CT scanner), or the flexible sigmoidoscopy. The cologuard is a test that I use often in my average-risk patients, meaning they do not have a family history of colon cancer in either of their parents or any of their siblings. Essentially, this test kit is delivered to the home in a box that provides you with everything you need to leave a stool sample. Subsequently, this does not require bowel prep or sedation. You can arrange for a pickup from your home, and the stool is then tested in a laboratory. The DNA in the stool is analyzed in order to look for changes that could indicate bleeding or a polyp. A negative test can be repeated every 3 years, while a positive test will require a follow-up colonoscopy in order to further evaluate what made this test positive. To be entirely transparent, there is about a 13% chance of a false positive reading. In other words, your positive test may really be a negative test. However, I personally do prefer using this modality as I feel that it is more of a sophisticated test than the FIT or FOBT.

The FIT and FOBT have also been used frequently. FIT is known as the f***l immunochemical test and FOBT is known as the f***l occult blood test. Both of these tests require a stool sample (which can also be done at home without bowel prep or sedation) and are looking for occult (hidden) blood. These tests are repeated annually and there is also a chance of false-positive results. Therefore, a positive FIT or FOBT would ultimately lead to a subsequent colonoscopy for further evaluation.

A virtual colonoscopy utilizes a CT scanner to obtain multiple images of the colon in order to detect any changes or abnormalities. This method does require bowel prep to best visualize these abdominal organs but does not require sedation. Another caveat to this modality is that if abnormalities are detected, there is no way to obtain a biopsy. So you guessed it - a colonoscopy would still be on the horizon. These tests are typically repeated every 5 years.

Lastly, a flexible sigmoidoscopy can be used as well. This essentially entails an evaluation of only the lower part of the colon known as the sigmoid colon and part of the descending colon. This also requires bowel prep but not always sedation. This method is not routinely used in screening, but more often for patients with various GI symptoms. It can be used as a screening tool for average-risk patients, but it is not the preferred method. Again, any changes or abnormalities will then lead to colonoscopy. Similar to a virtual colonoscopy, this test can also be repeated every 5 years.

You may have likely come to the conclusion that all roads can eventually lead to colonoscopy. The American College of Gastroenterology (ACG) prefers colonoscopy and FIT, and recommends the other modalities only when patients cannot complete the preferred methods for whatever reason. In my personal practice, I prefer cologuard over FIT testing and I do strongly recommend colonoscopy especially in high-risk individuals. High-risk individuals include those who have a first-degree relative diagnosed with colon cancer or an advanced polyp especially before the age of 60. A first-degree relative would include parents and siblings. Other higher risk individuals include those with inflammatory bowel diseases like Crohn’s and ulcerative colitis. Unequivocally, colonoscopy is the most appropriate modality in higher risk patients given the ability to immediately obtain samples of abnormal tissue and therefore, earlier detection of potential cancer. Unfortunately, other screening modalities have a higher likelihood of missing the presence of small polyps or scant bleeding.

Now I realize the idea of a colonoscopy sounds like voluntary torture to some, however, I think the bottom line here is considering what your individual risk may be and how can we best combat that with the tools we have. Not only that, but it is also important to take into account which test would provide us with the most confidence in the results. The more thorough a test is, the more likely it is to detect a malignancy. A less sensitive test may be more convenient in that it will not require sedation or time off work, but it may fail to detect an abnormality. Additionally, another important aspect to consider is what type of follow-up we are willing to undergo and how often. Do we mind packaging up a stool sample every 3 years and sending it off to our friendly UPS driver? Or would we rather do this annually? Or how about drinking a gallon of laxative for bowel prep potentially every 10 years? Despite the touch of sarcasm, all of these things are truly valid points to consider when determining the most appropriate screening tool given our own genetics, risk factors, and family history.

Most importantly, I would like to stress the importance of screening regardless of which method you may choose. Colon cancer may not give you any clues that it is present – in other words, you may not have any symptoms at all to let you know that you may have cancer. Patients frequently ask me if they would know if something was wrong, and truthfully, you may not. Often times, if we develop symptoms this can unfortunately be a sign that things have progressed. Thus, we implement screening practices in hopes of early detection and hopefully more conservative treatment options. My uncle (who is considered a second-degree relative and would put me at average-risk) was diagnosed with colon cancer in his 50’s on a routine colonoscopy. Ultimately, I have a laxative and the colonoscope to thank for the fact that my uncle is alive and well over 20 years later. He is in our lives and the lives of his grandchildren because he chose to get screened. It may have been a simple decision for him at the time based on his doctor’s recommendation, but it was a decision that allowed him to be present in this lifetime – for that, I am eternally grateful.

Just one more fun fact before you go... the updated 2021 guidelines for initiating colon cancer screening now recommend screening at the ripe old age of 45 and not 50! Unfortunately, the increasing cases of colon cancer in our younger patients have prompted this revision to the guidelines. Studies are currently being done to explore a possible correlation between processed foods and the higher incidence of colon cancer.

Lastly, if you take anything away from the topic of colon cancer screening, then let it be this – everybody p**ps!

Love and health,
Dr. Balov

Raise your hand if you have ever tried to lose weight. Now raise your hand if you felt you were successful. Now raise your hand if you were able to keep the weight off. I am sure the number of hands has gone down and I am here to tell you it is not your fault. Of course, a sedentary lifestyle and processed food do not help matters, but there is so much more to losing weight than a healthy diet and exercise. Genetics and hereditary makeup contribute significantly to a person’s body habitus. Not only that, but also any endocrine abnormalities like hypothyroidism can hinder a person’s ability to lose weight effectively. Thyroid function can appear well controlled on routine blood work, however, this can still impact weight loss. Not to mention, the way in which foods are processed in today’s times versus about 30 years ago has differed significantly – it is no coincidence that the rate of diabetes has skyrocketed in the past 30 years. Unfortunately, all of these factors do not promote successful and long-lasting weight loss and I would just like to drive the point home that this is not for lack of trying on your part.

Luckily, there is a new kid on the block that may revolutionize our relationship with the scale. GLP-1 medications have now hit the market and are showing promising results in the realm of weight loss. GLP-1 medications, also known as glucagon-like peptides, mimic a hormone that naturally occurs in the small intestine to stimulate the release of insulin. Insulin is another hormone that allows cells to take up glucose (or sugar) in the body. Therefore, most GLP-1s are indicated for the use of controlling blood sugars in diabetic patients. However, these medications have also demonstrated a particularly favorable side effect – weight loss!

Now how does this happen? GLP-1 medications also delay gastric emptying. In other words, they slow down the rate at which your stomach empties itself of food which results in feeling full longer. Portion size tends to dramatically decrease as a result as well. Ultimately, food intake and appetite are affected and therefore promote weight loss. Due to the way this medication works, common side effects may include nausea, vomiting, and diarrhea. Anecdotally, I have not had many patients experience vomiting and most have expressed to me that the nausea is typically short-lived. On the other hand, I have had some patients experience constipation rather than diarrhea likely due to eating less. If my patients wish to continue the medication despite side effects, then anti-nausea medication and stool softeners can be used as needed if desired.

The most common GLP-1 medications on the market are semaglutide (brand name ozempic or wegovy), dulaglutide (brand name trulicity), and tirzepatide (brand name mounjaro). Tirzepatide is slightly different in that it acts on two different types of receptors – it is not only a GLP-1 but also what is known as a GIP. For those of us that like to geek out on pharmacology, GIP stands for glucose-dependent insulinotropic polypeptide. Despite the long complicated name, it is essentially another hormone that causes insulin to be released in response to a meal. These medications have been shown to produce results, but not everybody is a candidate for them. More specifically, these medications are contraindicated in patients with personal or family history of medullary thyroid carcinoma (MTC is a type of thyroid cancer) or multiple endocrine neoplasia type 2 (MEN 2). What we mean by contraindicated is that we would not recommend taking this medication due to potential harm. What we mean by MEN 2 is a rare disorder that can cause tumors in the endocrine glands such as the thyroid, parathyroid, or adrenal glands. Thyroid tumors have been found in studies using rodents, but have not been found in humans at this point; however, we still recommend against it in anyone with this relevant history. Ultimately, more studies will need to be performed to further investigate this possibility.

Historically, medical weight loss typically came down to stimulant medications that help to suppress appetite. One of the more commonly used medications is phentermine. I have prescribed this medication often for patients and have seen results, however, as a stimulant we have to monitor closely for the subsequent side effects. Side effects may include rapid heart rate and palpitations, increased blood pressure, and insomnia. For my patients that have a history of hypertension (or high blood pressure) this may not be the best choice. Often, phentermine is combined with another drug called topiramate (brand name topamax). Topiramate is traditionally an anti-seizure and migraine prevention medication and comes with its own list of side effects; however, most importantly for my younger female patients, this medication can potentially cause birth defects and we strongly advise women of child-bearing age to also take birth control along with this medication. Subsequently, these medications come with certain stipulations and may not be appropriate for everyone.

Plenity is another weight loss option that is not actually considered to be a medication. It does require a prescription, but these are capsules composed of gel particles of cellulose and citric acid. These capsules are to be ingested prior to breakfast and lunch daily. Cellulose is a fiber found in plant cell walls and when administered with citric acid, it can be used to aid in weight loss by the way it can expand in the stomach once ingested. Thus, by taking up space in the stomach these capsules will promote smaller portion sizes and likely feeling full faster than we normally would. In essence, these capsules promote weight loss with portion control. The cellulose and citric acid gel particles do break down in your colon and are excreted in the stool without actually being absorbed by the body – this is also why it is not considered a traditional medication. Plenity is an out of pocket expense as most insurances do not cover it and typically requires it to be administered through a specialty pharmacy. A 1-month supply typically costs about $98 while a 3-month supply will cost approximately $250. It is FDA cleared as well.

Now, every medication will have side effects simply for the reason that every medication has to be processed through the liver and kidneys and certain breakdown products can result in side effects. Not to mention, the mechanism (or the way it works) can cause side effects as well. However, in order to determine if a medication is right for you depends heavily on your own body chemistry and risk versus benefit of the drug in question. Every person and every body is unique – what works for one person may not be best for your neighbor and that is ok. If side effects are minimal to none and we see benefit, then that is the most desirable outcome. If side effects are terrible and make my patients feel worse, then let’s move on and go a different route. Remember, this is about your overall well-being. I am not a physician that treats every ailment with a prescription, but if a medication exists that is more helpful than harmful, then let’s utilize science and medicine to our advantage.

Lastly, this is about more than the number on the scale, this is about feeling good in your skin, feeling good when you slip on those jeans, and feeling more confident in your own health and well-being. This is about not shying away from mirrors but embracing your projection. Taking off weight is not simply for a superficial benefit, but it means reducing the potential complications of obesity – heart disease, heart attacks, stroke, diabetes, and sleep apnea to name a few. This is about your health and taking control of your future health as realistically as we can when faced with the things we cannot control – our genes, our food sources, and certain diagnoses. This is about you and what nourishes your mind, body, and soul.

Love and health,

Dr Balov