Positive Gene Podcast: Ep #11: Colorectal Cancer Awareness, Genetic Risk, and Breaking Barriers to Screening with Dr. Fred Gandolfo.

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SARA: This is Sara Kavanaugh and today we have a very special guest, Dr. Frederick Gandolfo, a board-certified gastroenterologist and host of the Real GI Doctor Show.

As a practicing physician and educator, Dr. Gandolfo is dedicated to empowering his patients with knowledge about gastrointestinal health, preventative care, and the latest in screenings and treatments.

March is colon cancer awareness month and March 22nd marks Lynch Syndrome Awareness Day, two incredibly important opportunities to educate everyone on the role of genetic risk, early detection, and preventative care in colorectal cancer.

Dr. Gandolfo has firsthand experience treating patients at varying levels of risk from those with genetic predispositions, like those with Lynch Syndrome, like myself, to those with average risk.

Today, he's going to help us understand what we need to know about colorectal cancer risk, screening, and prevention. In addition to his clinical work, Dr. Gandolfo hosts the Real GI Doctor Show, a one-of-a-kind podcast where he breaks down GI health in an engaging and accessible way. And I happen to be a listener of the show as well. His show covers real patient cases, the latest testing and treatment options, diet and lifestyle strategies for disease prevention, and Q&A sessions that answer listeners' submitted questions.

Dr. Gandolfo, thank you for being here.

Dr. Gandolfo: Thank you for inviting me on the show.

SARA: All right. Now, before we dive in, can you share a little bit about your background and what drew you to gastroenterology?

Dr. Gandolfo: Sure. I was a science nerd in school, and no one in my family went into medicine or anything like that. I just decided I wanted to do it with my life. I enjoyed the science and the mixing it with just being able to apply it to people directly, as opposed to in a lab. I just studied and got into med school.

After that, you just do your rotations and you see what you like. I don't have an amazing family story of someone that had a GI problem that made me go into the field. I originally wanted to be an orthopedic surgeon because I cut open my hand on something and I was like, "Wow, cool. Look at these tendons and things wiggling around in there. I should learn about this." I had to have surgery and everything, so that was the coolest thing.

But then you go through med school. You go through all different rotations. You try everything out. I wanted to be an orthopedic surgeon, then a cardiologist, then a general surgeon. Every time I saw something, I thought that was what I wanted to do.

Then I eventually did my gastroenterology rotation. It was the coolest one that I did. It's just a feeling. You just like it. That's kind of it. I like the ability to see people and work with your hands, kind of 50/50. That's really it. That's the story with gastro. It's interesting. It's fun. You get to play with your hands and tools and stuff and do procedures and also use your brain.

SARA: Let's start by talking about the role of genetics in colorectal cancer. Many people don't realize that colorectal cancer could have a pretty strong genetic component. Can you help us break down the role of genetic predispositions like Lynch syndrome in colorectal cancer risk?

Dr. Gandolfo: Sure. I think just to take a step back at colorectal cancer in general, it's a super common cancer. It is getting more and more press and realization now because there are some awareness movements and things like that. Also, it's kind of moving up in the ranks of deadly cancers, which is unfortunate. It's moving into younger people a little bit too, which I'm sure we'll touch on.

It's currently the fourth most common diagnosed cancer in the United States. It's like the second leading cause of cancer death in men and women. That's not a great statistic for colorectal cancer in general. This is just all comers. In 2025, 150,000 people will be diagnosed roughly with colorectal cancer. About 53,000 will die from it. That's the latest stats that are out there. Most people think that it's funny because in just the population at large, patients at large coming in for screening or just for general other stuff. We kind of bring up screening as an important thing.

Most people have that feeling that it's not in my family. Therefore, it's not something I need to really worry about. In fact, like you touched on, most cases of colorectal cancer are sporadic, meaning you don't have a family history. You don't really have that identified genetic predisposition to it. It just happens. That's like 70 to 85% of cases of colorectal cancer are just sporadic chance.

Now, there's factors that go into that that we'll talk about, but that's the biggest misconception. For all people with or without genetic predispositions, it's really a common cancer. Then if you break it down a little further, 15 to 30% of the rest of the people, they have either a family history or a genetic predisposition to colorectal cancer. Lynch seems to be the number one, but it's still only about 2 to 4% of colorectal cancer cases are people who are found to have Lynch syndrome. There's a couple other genetic syndromes in there. FAP is another one that we see where people get lots of polyps in the colon, and that puts them at risk of colon cancer, but that's less likely. It's less than 1% of the colon cancer diagnoses or people who have it have this FAP situation. There's other unidentified genetic syndromes, so 10 to 20% of people who don't have Lynch or one of the other genetic syndromes that we know of, they have some undefined syndrome, something either we don't know of or something that's just a mix of different genetics that there's a family history out there, but there's no identified syndrome quite yet.

SARA: After you have a conversation with a patient, you start to understand maybe there is a little bit more history in their family or prompting them to ask that question. How do you approach discussions with your patients then about genetic testing? It can be a little bit of a sensitive topic for some people, especially maybe they're not close to their family members or not comfortable asking questions. How do you approach that discussion?

Dr. Gandolfo: Yeah, sure. This comes up somewhat frequently because you do take a family history with respect to cancer as part of the standard intake for a new patient. Really, if you come in for any reason, you come in for acid reflux or abdominal bloating, we still take that family history. Every once in a while, you find a pretty convincing family history, and I often will ask them, "Hey, have you ever been tested for a syndrome?" I'll just ask them ... It's just a normal question, I think. Most people will say no, and some people actually say yes, like someone picked it up or their family was tested for it or whatever it was.

But that being said, I just kind of ask them if they want to be tested. I'll explain to them the situation that there are these genetic syndromes that are out there. Some of them are pretty common. I'll often mention that they are underdiagnosed, meaning that there's lots of people walking around with this stuff and they never find out until they develop the cancer that defines the syndrome. Then they wish that 10 or 20 years earlier, they knew about this so they can get screened more aggressively and prevent the cancer from happening. If we identify a family history that's concerning, I'll often just ask them if they want testing. Then when people are hesitant to do the testing, I try to ask why that is.

Unfortunately, lots of times people are hesitant because of things that I never really thought of until I started asking the question. They'll say, "Hey, I'm up for my life. I want to get life insurance and I'm afraid that if I get tested and I have this thing, I won't be insurable," which is kind of a sad state of affairs. That has to do with insurance and everything. That's a reasonable reason, but still it's unfortunate because it kind of goes against what you'd want to do for the person or what the person wants to do for themselves.

But a lot of times I notice that people don't want to get tested because of either anxiety about the results or that fear of, "If I don't know about it, it's not going to hurt me." That's a harder thing to chip away at. It's hard when you're seeing patients as a clinician. It's very challenging to figure out how much you want to help that person make a decision that seems like the right decision and how much you want to be just to try to guide them to the right decision. If you push too hard, if something seems like a really good decision to you as a physician, and you push too hard, you can turn people off and they can think that you're trying to be paternalistic and push stuff on them. But if you don't educate or push enough, some people just think it's not important. Like, "Oh, he just said it's a maybe type thing," whatever, and then they don't think it's important either. So I feel like for every person, it's a fine line. That's the doctor-patient relationship. You really have to develop that relationship. So sometimes I just bring it up as a possibility. And if it's not really why they're there and they don't really want to do it, we table it and I make a note to bring it up in the next visit. Like, "Hey, did you think about that? Or did you ask your mom if there was anyone else in the family?" And a lot of times people will have thought, you know, in the subconscious, in the background, they'll think about this stuff that we talk about and they'll say, "Hey, I do want to get tested." And that's fine.

We offer the testing right in the office. But I have to say that like 90% of people, and that's not a scientific number, but that's just like my own anecdotal observation. If I mentioned that there's a test for a genetic cancer syndrome and that they might fit the criteria, especially with some insurance companies, which are pretty good at paying for it if you have that family history, they're all for it. I mean, I practice in New York on Long Island. I feel like it's a very, I don't know, there's a lot of cancer or there seems to be a lot of cancer out here. And maybe everyone thinks that. And lots of people are very on top of the news and stuff. So it seems like people are almost asking me for these tests sometimes. So I don't get a ton of pushback.

SARA: Yeah, yeah, that's good. You see it firsthand. And it's great that you work in a community where people are fairly well educated on cancer risk and really how they approach it. That says a lot about your community investing in what's important for their long-term health. So that's pretty cool. You know, we've had a couple of guests on the show who are known in the hereditary cancer space, Kathy Baker of My Faulty Gene and Wenora Johnson from FORCES Board of Directors. Both of them shared in their stories that it took their physician to push them for years to get the genetic testing or in Wenora's case, to do her FIT test where she ended up finding out that she had colon cancer, right? So we appreciate as the patients who are spending a lot of time with you guys throughout the years, appreciate that being persistent.

And you do bring up really good points. Like I have shared this in past episodes with some of the concerns that people have, the pros and cons, right? Of getting genetic testing and sort of what comes along with that experience. I would encourage anyone to go back to those episodes and just hear firsthand perspectives from people who have been there.

SARA: Okay. I was going to ask about cascade testing as well. If you do have family members testing positive, can you talk to us a little bit about the importance of cascade testing if somebody does have a positive result in hereditary colorectal cancer, I should say, if we want to get that specific.

Dr. Gandolfo: Sure. Yeah. No, it's an important thing. And it's the next natural conversation that just happens. If you send someone for genetic testing and two weeks later, you get this report back and you find that they have a syndrome, then cascade testing, meaning testing their family members, first-year relatives is very important. So again, it's one of those things that you don't necessarily, I kind of added as a footnote to the visit because people often are kind of freaking out about their own situation now. And they're learning as their, you know, the anxiety and the processing is happening at the same time as they're learning about stuff that they've never really heard of before. And this happens a lot in medicine.

So you kind of have to like learn to manage that, those dual processes of, you know, you're giving someone information and that they don't know what Lynch syndrome is most of the time. And you're trying to explain like, Hey, this, you have this thing and here's going to be like the next rest of your life in terms of like how we're going to do screening and more aggressive things. You have to go for visits here and there. These are all things to watch out for.

So their head is spinning and then you're like, by the way, tell your mom and your dad and your brother, you said, they're kind of like, yeah, okay, whatever. I'll get to that. So a lot of times I just bring it up. And it's the same way as, you know, if you do it colonoscopy, for example, and you diagnose someone with a colon cancer that wasn't really expecting it, or maybe was expecting it, but now it's a reality, you find a tumor there. And this is like all comers, not just like Lynch syndrome, just people in general coming in for a procedure and having some finding, stomach cancer, colon cancer, pancreatic cancer, whatever it is. It's not always like the, I guess the best time to bring up the family testing, like in that same conversation.

So oftentimes, I would kind of add it as a footnote and say, Hey, just so you know, a lot of these things are, have genetic underpinnings. And it's very important that you talk to your family about this. And then, you know, the next time we maybe say, it's time to talk to your parents and time to talk to your siblings, time to talk to your kids about what to do in terms of testing, because you have this thing, but you want to help prevent them from having it. So it's again, it's one of those things, it's a few visits, you have to really, you don't want to push them, it's too much information sometimes.

So it's very important, because if you do test families downstream, from people who have Lynch syndrome, you often will find several other people have it. And then you can get on those people for earlier, more aggressive screenings, and then they won't hopefully develop that index cancer. So I think the number is about three for every one person who you diagnose with Lynch, you can find about three more if you do this cascade testing. So that's pretty nice, because their diagnosis leads to potentially three more people being able to prevent that first cancer by aggressive screening.

SARA: Yeah. Initially, I was going to shift to the signs and symptoms to watch for, but we have mentioned Lynch syndrome multiple times here and feel like we should take a step back and really explain a little bit more about Lynch syndrome. Just for those that are listening to this, starting with this episode and not going back to prior episodes, we spend a little bit more time talking about Lynch. And since we're sharing this episode around colorectal cancer awareness month and Lynch syndrome awareness day, can you give a little bit of background on Lynch syndrome for our audience?

Dr. Gandolfo: Sure. So it's a genetic cancer syndrome. It's a defect in these. It's always like you don't always go back and talk more and more. So I don't want to make it like a long lecture that leads back to things that I don't know about in cellular biology anymore. But what happens is, it's a genetic cancer syndrome. It's a, it's a defect in mismatch repair gene. So when your cells divide, there's lots of stuff that happens. And there's mistakes that can be made when you're copying DNA. And the body has multiple mechanisms to look out for these mistakes and to take those cells out of production, basically, and to tell them to die and be recycled, because they're not normal cells. And so the mismatch repair is one of the mechanisms for preventing DNA damage and mutations. And there's certain genes that are involved in this that if they're not working properly, or if they're mutated, then that's Lynch syndrome.

So you get these, these mutations that lead to or that allow cancer to happen. And the main genes with Lynch, they're mlh1, msh2, msh6, and pms2. Do I have those memorized? No, but I see them all the time in reports. So I know what they are. And I always look this up because unless you're a geneticist, I think that, you know, everything kind of starts to blend together with some of these names of these genes.

But it's important to know your mutation, because some of them have different rates of cancer than others, some of them are a little more aggressive, a little less aggressive. And, you know, if you look at different guidelines, how to survey people, or how to screen people for Lynch syndrome associated cancers, you can sometimes go by the actual mutation they have with some being a little more aggressive than others.

Some people in the US, we kind of start earlier, but if you look at like the some of the international guidelines, some countries advocate, like the UK advocates for starting screening later, and some people have a less aggressive mutation. But I think what happens is, you know, you get these cancer, there's certain cancers that people with Lynch are more prone to. And there's a few and there's a few that are very common, and there's a few that are less common, but associated with Lynch. And I think the biggest, you know, the biggest ones are colorectal cancer, endometrial cancer, ovarian cancers on that risk, although it's on that list, although it's not often thought of as a Lynch cancer, it has a association. And then there's cancers of the urinary tract, the kidney, the urinary, the bladder, these are often cancers related traditionally to smoking, but in Lynch, they're elevated also. And there's less common cancers, but also Lynch cancers.

In terms of the gastro system, it's the stomach, so the gastric cancer, and even small bowel cancer. So we often survey people for those things. Pancreatic cancer is also in that Lynch category. And prostate cancer and breast cancer are also there, although at a lesser degree. So that's Lynch syndrome. Once you identify this, the family history, or you find a tumor in a person who shouldn't have a tumor there, a younger person, or who has a constellation of different things, different cancers in this Lynch category or possible Lynch category cancers, then you screen them genetically, you find one of these mutations that kind of defines someone having Lynch syndrome. And then you need to plug them in for looking for all these other things that could happen.

SARA: Yeah, for sure. And I know firsthand, I have MSH6, and so I have a grandmother who had had a "female cancer" sometime in her 40s. And that was a time they didn't really talk about it. I didn't even know this until I reached out to one of my relatives to find out our cancer family history. But yeah, so that was one of the reasons that led me to get my hysterectomy. One less thing to really worry about in the long run. And then as an MSH6, as you mentioned, the increase of colorectal cancer, I also have a relative had colon cancer. And so I was already on, I think, the five-year plan before I was tested for my Lynch syndrome. And now I'm on an every two-year cycle because I've never had polyps in that time period. I think if they ever were to find anything, he would probably put me on an annual rotation at that point. And then I have an upper endoscopy done every four years, a history of acid reflux. And so, but I've never had like H. pylori or anything like that pop up. And they tested me for Barrett's esophagus and all the things that could lead to, you know, a diagnosis potentially down the road. So we're definitely on top of it. But I share my experience specifically for those that are listening to the Lynch syndrome perspective specifically. But other screenings that I do have are, I have an annual skin screening as well. And then I do have a rotation from that, not that my breast increased risk, breast cancer risk isn't related necessarily to my Lynch syndrome, it's more to my CHEK2. But I do rotate every six months of mammogram and a breast MRI. So we spend a lot of time doing that rotation. But for me, it gives me a lot of peace of mind to know that, hey, I'm on top of this, should something come up? I will be prepared in some way or ahead of the game anyway.

So okay, let's switch gears and really talk about the most common warning signs of colorectal cancer, and why they often go unnoticed or misdiagnosed?

Dr. Gandolfo: Sure, it's tough. Because like you said, the GI tract, the more I do this as a physician seeing patients, the more different ways people describe things to me. So it's very easy to kind of get a list of symptoms from a patient. And it doesn't even make sense, but they have some other thing. And you kind of like recalibrate your thinking.

So yes, I mean, the most common things for colorectal cancer, just to be clear, it's usually rectal bleeding, abdominal pain, change in the bowels. So someone who's the stool caliber changes, or you're going to the bathroom more frequently than you used to go, or you're going less frequently than you used to go, like having a new onset constipation, those things are all concerning changes. The bowels look different than they used to people, you know, everyone comes in with complaints of not everyone, but people often come in with complaints of that their stool is flat or small caliber, or it looks like a pencil, thin type movement, and they're concerned that they have cancer.

You know, often that's actually just from a low fiber diet or your bowel syndrome is the most common thing that gives you that. But those are all things to look out for. And the other thing is weight loss, you know, weight loss is one of those really objective signs, along with other things, blood tests to show anemia and other findings.

But the big four, if you're looking for people who you should seriously consider colorectal cancer testing for, really despite the age at this point, within reason, it's really 1) rectal bleeding, 2) it's change in the bowel habits, 3) it's weight loss, and 4) it's abdominal pain. And that abdominal pain thing is very vague, because sometimes you can have pain from the tumor itself, but often you don't have pain from the tumor, you have pain from some type of blockage or some problem moving your bowels. And that's already means that there's something that's there for a while, you know, you don't usually get pain as the first symptom, the first symptom of colon cancer is nothing.

That's the problem, you know, it's a very, it doesn't really give you if you think about it, colon cancer doesn't usually give you a symptom until like, like people always ask are, you know, the polyps, which are the precancerous growths that you got for many years before colon cancer? Do those have symptoms? And for most people, the answer is no, the vast majority, they don't have symptoms, the bowels just kind of move past the polyps, and there's nothing to look for. But the end cancer is the same way until it's big enough to cause bleeding or to kind of interfere with the function of your bowel, you can have a can't you can have colon cancer for, you know, a year or two, or longer without really major symptoms.

Oftentimes, people present with anemia, just they're feeling fatigued, they come in with a low blood count. And they've been slowly losing blood for a period of a year or two from from a cancer from a tumor, but it hasn't caused an obstruction, it's not causing pain. And if it's somewhere, you know, deeper higher up in the colon, more toward like the right side of the colon, which is furthest away from the rectum, they often don't have any change in the bowel habits whatsoever. It's really the younger people who get to change in the bowel habits and the lower because they get they're more prone to having rectal cancers like lower down in the GI tract.

SARA: So when you mentioned that finding blood is, you know, at some point going to trigger somebody to reach out to you question that comes up often is how do you know that it's not being caused by hemorrhoids? How can you describe to somebody because we're going to we're going to get really into the weeds here for a second because I talked to a lot of people that have colonoscopies on a regular basis, and we just get really personal. And so I think this is a question that comes up or people find that they suspected that it was hemorrhoids. And so they didn't do anything about it until it reached a certain point when it was, you know, found out to be cancer.

Dr. Gandolfo: Yeah, so it's an important question. And it's a question that I have to answer. I have to do the mental arithmetic basically, like every day, because this is a very common complaint, especially amongst young people, a little rectal bleeding, I see a little blood on the toilet paper when I wipe a little bit of bright red blood, or I see a little blood on the stool, like you go and you just see a little blood on the outside, but the stool itself is normal. Or I see a couple of drops of blood in the water or a little bit of blood in the water on occasion, like it happened a couple of weeks ago, I made the appointment, it hasn't stopped hasn't happened again since then. But it's happened maybe six months ago.

These are all hard things to tease out. And the truth is, there is no way to tell without, without looking. So, you know, there are some reassuring symptoms, if it's on and off leading that happens once every few months in a person who and mostly it's just a little bright red blood on the toilet paper. That's usually some anal rectal source of bleeding either hemorrhoid or a fissure. But I've been I don't want to say burned because we looked and we found the thing but I've been kind of almost fooled before where someone comes in with a similar issue like that. And we eventually say hey, enough is enough.

Let's just look in a 30 year old and you find like a really big advanced polyp in the rectum causing this like a big adenomatous polyp, which is the precancerous type polyp. So that's a person that would have went on to develop an early onset colon cancer. So I think it's important to take the rectal bleeding thing seriously. And if it's happening more than a few times, the general rule of thumb is it happens more than once or twice and you're seeing blood in the toilet water, not just like a drop or two on the on the tissue. I mean, some people are like dissecting their stools and looking for a drop of blood. Is it that? Is it the beets that I ate yesterday and salad like that kind of stuff typically is not very worrisome. But it's the it's the bleeding that happens frequently or more than a few times or it's associated with one of those other symptoms.

Either weight loss, obviously, is it something you don't want is it's like usually a late symptom, but weight loss or abdominal pain or some change in the bowels themselves, you know, that goes along with the rectal bleeding. That's always a concern. So I think my you know, the general rule of and I have this conversation with patients often too, like the general rule of thumb used to be if you were like 40 to 50 or so and you had occasional rectal bleeding, let's think about doing a colonoscopy. And now that has kind of shifted to if you're 30, if you're 26, if you're 25, like a lot of times we'll offer or at least I will offer colonoscopy a little earlier than I was taught even in fellowship, you know. But even the teaching then was like, you know, colorectal cancer or something that happened to people in their 40s, 50s, 60s and not really in their 20s, 30s.

But we're I think there's been more awareness due to all this, you know, these campaigns and education, social media patients looking for stuff by themselves, I think it's great that people can get stuff when they're earlier. And even if it's just a big polyp, I mean, how many polyps do you find in 30 year olds? I find them all the time. So it's interesting.

SARA: Well, yeah, that's the perfect segue into our next question, which is the troubling rise of colorectal cancer among younger people. So what factors do you believe may be contributing to this trend?

Dr. Gandolfo: So it's right. It's tough one. I don't think anybody really knows what's happening. There's a lot of guesses out there. There's a lot of hypotheses, but I don't think there's any ever been like a true cause that's yet to be identified for this rise in colorectal cancer in younger people. I don't think it's just an over diagnosis because they're there, you know, the cancer is going to present itself, you know, earlier screening and things could detect stuff earlier and give you what's called like a lead time bias. And you find something a little earlier than you normally would. But I think these cases are real. I mean, they're going to present either way. So it's not like a made up thing.

And it's been going on since the 90s. The rate of colorectal cancer in younger people, meaning like less than 50, 55 years old, has been rising since the 1990s by a couple of percent every year, one or two percent. So it's now eclipsed other cancers and now colorectal cancer deaths are the number one cancer killer in men under 50 and number two in women under 50. So it's a real thing. And what's causing it? I don't know. But I think the ideas are that maybe it's what we're doing diet wise, maybe it's the general levels of processed foods that we're eating, or maybe it's that we're eating too much too much food that's processed with emulsifiers or too much salted and cured red meats. You know, these are all theories that are thrown out there.

I think in general, we do eat too much processed food in the country. It's not like a surprise that we're not really all preparing our meals from home, you know, from foods that we find in the in the earth, we're eating a lot of convenience foods and junk foods and sweets and things. And there's probably a place for that in the diet, maybe if, you know, 10% of the diet can be like that. But you really shouldn't be eating that as 80 to 90% of the diet, which a lot of people are. And, you know, we're not eating enough fiber and all these things. Now, is that different in the 80s? I don't know. I can't speak for that. But I think there's a couple of different theories out there.

You know, one of them is just the processed food. Lots of people are living like a sedentary lifestyle now where there's a lot less physical activity going on. And that's been linked to, you know, increasing colon cancer in general, not having enough physical activity. Obesity is a big one, obesity rates and over people who are overweight that those rates have been going up, I think pretty much every year as a standard thing. And that's strongly linked to all cancers, not just colon cancer, but definitely colon cancer as well.

And alcohol is another one. I mean, alcohol has kind of infiltrated society, and it's not good for you in general. I mean, it's I think we know that now, but no one wants to know it. But we do know that alcohol is definitely a carcinogen. It does, it does increase your risk of colon cancer and many of the GI cancer, stomach cancer and small bowel cancer and esophageal cancer, but definitely colon cancer. It's a big risk factor. And we see it all the time. And people who drink even just moderate, you know, drinking, a drink or two a week, it does have a measurable increased risk in colon cancer that's not trivial. So you do have to literally pick your poison there. You can probably enjoy a little alcohol here and there, but understand that there's no healthy amount with respect to cancer risk. And there's a million other things that go along with that. That's beyond the scope of this. But alcohol is a big one. And alcohol has infiltrated everything. I mean, everything has a glass of wine attached to it now. And, you know, kids birthday parties, people are drinking, parents are drinking at where 20 years ago, that wasn't a thing. It's, you know, a daytime birthday party for a kid. Everything is centered, seems to center around alcohol. So it's a little too much. And it's a big carcinogen, you know, breast cancer as well. Alcohol is a big risk factor that's under discussed, I should say.

And then I think there's more, I mean, there's more things that we can talk about this. There's theories about antibiotics, overabundance of antibiotic use, maybe changes the gut microbiome in terms of a pro carcinogenic state. That's been a theory that we've been overusing antibiotics since the 80s and 90s. And that's still going on.

And there's all kinds of conspiracy theories of pollutions and micro plastics and other things that may or may not be true. And I think they're just going to take more time to be discovered as risk factors. I'm sure we'll figure it out eventually. But you know, we can only do what we can with the knowledge we have at the moment.

SARA: Yeah, absolutely. And a lot of the things that you mentioned are things that you can do something to reduce your risk, right? By watching your weight, watching what you eat, don't smoke, watch what you're coming into contact with in the environment. A lot of what you described in terms of what is increasing that risk, setting genetics aside, there's a lot that you can do to reduce your cancer risk. So thank you for covering those. That's really important.

Okay, let's talk about the importance of early screening. So we know screening is key, but there are still a lot of barriers that are preventing people from getting colonoscopies. So let's talk a minute about the biggest misconceptions about screening. And then we'll dig a little bit deeper on that when it comes to the guidelines.

Dr. Gandolfo: Sure. So the biggest, I think the biggest thing that prevents people from coming in to get screened is just that they know it's not entirely either convenient or comfortable, or it's just intrinsically a little gross, or they just don't want to think about it or talk about it, because it just seems like it's just a gross thing to talk about their poop and their stool and what ever. But we all do it. So I think at the end of the day, some people just don't want to deal with it. And I don't know why that is. People don't want to do a lot of things they should do.

It's, I think the biggest misconception amongst people who want to do screening are that it's, and we'll talk about colonoscopy, because that is the major screening test. We'll talk about some other ones, but that's the best one we have. People know that there's some degree of bowel preparation that they have to do in terms of they have to drink some stuff or take some pills and get cleaned out. They know it's not going to be super fun. They're afraid that it's going to be painful. They're afraid the procedure is going to be painful.

I think it's a misconception about the risk involved with colonoscopy. That is some high risk procedure that's only done occasionally. And in fact, it's actually a very low risk procedure and it's done very commonly.

So, these things you can kind of break down with the individual person on a person by person basis and just talk about it. So a lot of people just show up. I have tons of people who were 45 on the dot. They just turned 45 a month ago and they're coming in for their screening colonoscopy. There's been a lot of awareness and a lot of barriers have been broken, I should say, but there's definitely a big room for growth because there's a lot of people out there who do not get screened. And that number is significant. It's above 20%, 25% of people out there don't have any screening. I've seen figures that are even higher than that. I don't know. It's locally, I only see the people who come in for screening. So I don't know who else is out there in my community, but there's a lot of people who don't want to do it. And then we talk about other alternatives to screen, to colonoscopy.

Colonoscopy is really the only test that has the benefit of being both a screening test and also a therapeutic test that can reduce the risk of cancer by taking out polyps. So all the other tests that exist, they just identify something is wrong and then they lead to a colonoscopy. And the colonoscopy is actually the test that goes in and modifies the cancer risk by removing these polyps that can cause cancer. And we do that all at the same time as the procedure and it's painless and it's all done in about 15, 20, 25 minutes, depending on what's going on in there.

So that's pretty amazing that we can do this and you wake up and you walk out and you should feel fine. And that's most people's experiences that they wake up and they walk out and they feel fine.

I think these other tests that are out there are great if you're not going to get a colonoscopy. And it depends on the age of the person and their individual risks and their genetic risks, why they would prefer one or the other. And those tests, there's fit testing, which is basically a stool test to see if there's blood in your stool. There is a Cologuard test, which is a mail away test that checks for abnormal DNA in your stool plus blood in the stool. And there's also, now there's a blood test out called Shield, which is not amazing in terms of the way it works in terms of picking up cancer. But it's something, if you're not going to get anything, if anything done, that's a good third alternative test. It's pretty easy to get a blood test.

SARA: All right. That's really helpful because for me, it was immediately going right to colonoscopy because of my risk. I have not done any of the other tests because I go right for the gold standard. But I think helping the audience understand what other options there are is just one step closer, right, to helping them identify what the risk might be.

Dr. Gandolfo: Yeah. I think the best test is the one that you're going to do. So just like the best exercise program or the best diet is the one that you can actually do and implement in your life. So I have people who I tell you really should get a colonoscopy. It's the best. I can tell them a million times. I can show them how it is amazing and it's easy and give them anecdotes and stories. And they're just never going to do it. And that's fine. So how about a Cologuard? How about a different type of test? Because if you have something in there, if you have a polyp that's going to turn to cancer and you just ignore it, then that's like not good, right? So any other test rather than ignoring it is a better thing with colonoscopy being the gold standard best test, but it's not for everybody. So most people do it.

And people with genetic syndromes, especially Lynch Syndrome, colonoscopy is really the only test that you would think to do because you don't want to wait until a cancer develops because you know the risk is high. So there's no point in waiting for a cancer to develop. You want to get the precancerous polyp out years before. And we know that this kind of is a little off. It's on topic, but not this question, but Lynch Syndrome, the polyp growth to cancer is accelerated in some people. So we typically we cite about a 10 to 15 year period of time where if you start growing a polyp, it takes about 10 to 15 years for that polyp to turn into a cancer if it's going to happen. And it doesn't happen with all the polyps, but Lynch, that timeline is compressed and it could be two years, three years, five years in some people. So you do have to stay on top of it. And the point is you want to go and get that precancerous polyp and not let it get to the point where it's cancer or symptomatic.

And you know, a lot of these tests, these non-invasive tests, the fit test and the Cologuard test, they rely on blood or abnormal DNA. And by the time that is being expressed in the bowels, by the time something's bleeding, it's either already a very advanced lesion or it's already cancer. And then you've, you know, the point of early detection, it's gone. Now it's a reaction. Now you're reacting to the cancer. Now you're talking about surgery and other things where a year or two prior to that, you can avoid all that by just picking out the polyp and taking it out.

SARA: Yeah. While we're on the topic of colonoscopies, can you take us through just real briefly what the experience is like? You have prep. Some preps require you two days ahead to really start your like liquid fasting. And then you have your, your prep medicine. Like I use Clenpiq that seems to work better for me, but some people do the Gatorade and Miralax. That was the first time. That was awful. That's why I'm glad I'm on Clenpiq now. It's only two small bottles. But yeah, can you just real briefly take us through what that process looks like? You have an episode that you did on YouTube, put that in the show notes, where you take people through the prep experience. But if you could just real briefly take us through the process.

Dr. Gandolfo: Sure. So I'll use my experience. I'm a private practitioner. You know, people work in big companies, people work by themselves, whatever it is, but a patient decides, Hey, I should get a colonoscopy or I should get screened, I should say. And they either their primary care doctors tells them to get screened or they go online or they realize they're of the age to get screened. And that age is 45. If you don't have a genetic syndrome, that age is 45 to get screened. Men and women, no risk factors, no family history, no symptoms. It's 45 for everybody now. Used to be 50. That's old news now. So it's 45. Y

ou show up at the doctor's office, you make the appointment and we talk about colonoscopy. We take a brief history. We talk about what the procedure is. And that talk goes like this. I basically tell them colonoscopy is the gold standard test to prevent colon cancer. There's some alternative tests that we mentioned in the show. I'm not going to go into that again, but fit testing, cola guard testing. And those are the private best two alternative tests to colonoscopy. But if you really want to prevent cancer, the way to do it is colonoscopy. And if you do a high quality exam, high quality colonoscopy, meaning that the doctor and the patient are working together to get things done the right way, which I can touch on if you'd like me to, then you're protected. If you're average risk, you're protected for 10 years. If you have nothing going on in there and if you're, if we find something like a polyp or something else going on there, then sometimes we react, we bring you back earlier, either a year, if it's cancer, three years, if you have a few polyps, five years, if you have one or two little polyps. So there's different guidelines we use for that.

But colonoscopy, you come in, we talk, it's a meet and greet. We talk about the prep. The prep is very necessary. It's the most important part that the patient has control of. So the patient has control of like two or three things. One is picking their doctor, making the appointment and picking a doctor that's, you know, a decent endoscopist, colonoscopist, who's going to do a good job. And the other thing is that they have to do the prep properly. They have to actually do the clean out the right way. And the other, the third thing is that they have to show up for their appointment because lots of people come in all excited about doing a colonoscopy and they make the appointment, they get the prep and then they call and cancel 17 times and they eventually just don't do it. Five years later, maybe they show up and do it. Maybe they don't. That gets a little interesting, but that's the way it is.

But the prep itself is, it's the clean out stuff. And it used to be, you know, back in the day, it was a big giant gallon of stuff called Go Lightly or one of those brands. It was a four liter disgusting jug of liquid you had to drink and it was, it was hard to do. And the way it works, all the preps work kind of the same way. It's just, it's, it's like a salt solution with water. You drink it, it kind of flushes through you. So it cleans everything out from the inside. And at the end of the day, like your colon, even though you're moving your bowels normally and the people who are not constipated, there's still always some stool and liquid and gunk inside your colon. That's like the purpose of it. So to do the clean out properly at the end of it, you flush all this liquid through you, you get lots and lots of diarrhea, but at the end of it, you're basically going like tap water is coming out or champagne if you're fancy. So it's really, you're really going quite a bit.

And at the end of it, you're totally clean. So the colon, the lining of the colon looks as clean as the inside of your mouth after you're done brushing your teeth. That's how clean it gets, which is super important because we can, we need to see these little polyps. And the polyps are sometimes very subtle, very hard to find, you know, big polyps are easy to find, but little guys, little tiny polyps, little flat polyps are very subtle and sometimes very, very hard to find. So the absolute best thing you can do is do the prep properly.

And to do the prep properly, it involves a couple of diet changes. So a few days before you have to cut out like seeds and nuts and other roughage type foods, you know, healthy stuff, but you just don't want it before your colonoscopy because it sticks around inside for a few days longer than just, you know, white toast and simple foods like that. So you cut out all the beans and the skins of vegetables and things for two to three days prior and seeds and nuts and popcorn and all that stuff. And then after that, the day prior to the exam, you're on a liquid diet for most of the day, some of the more modern preps, you can actually have a light breakfast the day prior. So if you're having your colonoscopy on a Friday, for example, Thursday morning, you can have often a light breakfast, you can have some toast and some scrambled eggs. If you can afford eggs, you can have some toast and some yogurt or some Farina or something like that, you know, something very, very light, no fiber. And then you drink liquid for the rest of the day. So clear liquids of juice, water, broth, Italian ices, jello, Gatorade, whatever you like to drink.

And then usually in the evening, the day prior to the exam, you start the prep process. And it depends on just like many different types of things you can do to do prep. Almost nobody uses that four liter solution of Go lightly anymore, unless your insurance only covers that, which some of the plants still only cover that, which is crazy. Or if like none of the other preps work for you and you want to go back to the old gold standard prep from the 80s. We try not to use that prep anymore.

But some of the more modern preps, they're much lower volume. The one that you talked about, Clenpiq is a much lower volume prep. It's only two little bottles that are about 150 ml each. And then you drink lots of water with that too. And that kind of does the job. There's a bunch of preps out there that are about 16 ounces that you have to repeat. So 16 ounces of gross prep, and then lots of water after that. And then 16 ounces of gross prep again, and then lots of water after that. That's pretty much like the gold standard thing now is really like these reduced volume liquid preps. And then a few years ago, they came out with a pill based prep called Soutab, which is pretty nice too. So lots of people like that prep. It's basically the same ingredients as a prep known as Soutep, which was used for a long, long time. It's still out there. It still works great. That's the prep I use for my colonoscopy. That was the one that was the best one at the time. And I still give it to patients all the time. It's covered by insurance. And I don't have any brands. I'm not sponsored or anything. I just use these products in my practice. But basically, they came out with this thing called Soutab. And I have a video on my YouTube about that also. And it's 24 pills. They're about the size of vitamins. They're a good size. But instead of drinking that first 16 ounces of disgusting liquid, you drink 16 ounces of water with these 12 pills. And then you drink lots of water after that. And then you take a little pause, you go to the bathroom a lot. And then you do it again, you do another 12 pills plus all the water. And that cleans you out just as well as the liquids that I do. Some people get a little nausea from these preps or a little stomach upset, but they're pretty much, they're usually painless, meaning like it's not, you don't get cramps and stuff, you just go a lot. You just go to the bathroom a lot.

So you do all that at home, you go to the bathroom all night, you wake up and you get some sleep, you wake up in the morning, sometimes you do a little extra prep in the morning, sometimes you don't, depending on what time you come in, you show up to the office, you have to have someone driving you.

And we take it from there, we say hello, I tell you that it takes about 15 to 20 minutes to do the procedure. The anesthesiologist says hello, they put the IV in, you are asleep for it, you get some good sedation. Most places use propofol, which is the sedative of choice is given by an anesthesiologist, you go to sleep, you feel great, it doesn't feel like there's no, there's neither like euphoria or some sense of like nausea or anything like you get from general. You just kind of drift off the sleep, you wake up in the recovery room, you don't even know what happened, there's no sense of time or there's no discomfort. But you go off to sleep, you wake up . And I tell you, hey, do we find polyps? Do we not find polyps? But what I'm doing in there is I'm looking at the entire colon with a small flexible camera with a light on the end of it and has a little instrument channel in it. And I'm able to intervene with things like I could biopsy, I could take polyps out, you could do quite a bit of things with that little camera. And it's all done at the same time as the procedure for the most part. Sometimes you find something where it's an advanced polyp or something unusual, you have to bring someone back for another session, maybe in the hospital or maybe it's just a second session in the office because there's so many polyps, I've had those kinds of situations before, or really big polyps.

So you wake up and it's over in your home eating breakfast. And you take a nap for a couple hours, and you feel usually pretty good after that. And then it's done, then you have to worry about it for like 10 years. So it's a lot of anticipation and everything that goes into like this very quick procedure.

SARA: Yeah, yeah, but you're right. The cloud is lifted once it's over, you can go back and enjoy life until your next prep.

Dr. Gandolfo: Correct. And in all fairness, you know, I should, I just I'm like a colonoscopy salesman here. So I should also tell you that, you know, it's an invasive procedure, there are risks involved to colonoscopy, it's not a risk free procedure in good hands, meaning an experienced physician who does lots of colonoscopies and has a low complication rate, the real risks of a problem from a colonoscopy are extremely low, they're quoted as less than one in 1000. They're really probably less than one in 10,000 or so for like a serious complication.

Mainly the biggest one that people worry about is called perforation, it's like making a hole or tear inside the bowel. That's extremely rare. That's something that almost never, you could say it almost never happens, you can never say never. It's like saying I'll never get in a car accident, it could happen. But it's extremely, extremely rare. And then the other risks are bleeding. So you have to your doctor should ask you about blood thinning medicines and bleeding risks. Also very, very rare and there's ways around someone's prone to bleeding is things you can do during the procedure to really reduce that risk. But it's something that the doctor be aware of. And there's all kinds of oddball stuff that can happen.

Sometimes from the sedation, there could be reactions, usually not serious reactions. Sometimes people can have what's called aspiration, which is if you didn't do the prep, if you didn't finish the prep early enough, or if you're taking some of these newer, these GLP one agonist drugs like Ozempic or less people think Ozempic, somatoluside, Bonjaro, these drugs, they slow down the stomach emptying quite a bit and the gut emptying. And some people are taking this stuff like they're buying it either on the internet or they're getting it from like a local weight loss clinic, and it's not really even on their medicine list.

So you know, we make a point to ask everyone about that now because those can increase the risk of complications during procedures, you have to hold those drugs for a little while. So there's a couple of a couple of minor things to talk about, but that the doctor should kind of touch on that as well. But you know, cost benefit wise, colonoscopy, if about one in 24 people are going to get colon cancer in their lifetime with no screening, or I should say one in 24 people are getting colon cancer anyway, and we're screening lots of people. So the risks are real, the risk of some catastrophic complications from colonoscopy, extremely rare if you go to someone good.

So you just have to be careful, you have to pick your doctor wisely. It's always hard to find out who's good and who's bad, right? Because you're asleep for the procedure. So you have to kind of ask around and no pun, but you have to listen to your gut when you meet somebody, do you think they're really out for your best interest? Or are they just trying to like push you in and out as fast as possible through the office? And that's, that's a feeling that you get when you meet your provider.

SARA: Yeah, absolutely. That's great advice. Okay, let's can we switch gears here now, we're getting close to wrapping up. And I just want to talk about risk reduction strategies. So beyond screening, what are the best ways to lower colorectal cancer risk? We've talked about a bit about diet, lifestyle and other preventative measures. But what advice can you give to our audience and reducing the risk?

Dr. Gandolfo: So yeah, I mean, there really is no, I say I should say there's really no magic out there. We we don't have like some like super food that we say to take or a probiotic or some intervention that you could just actively do to reduce the risk. It's kind of like good old fashioned healthy living, it really still is. So it really is it's a diet high in fruits and vegetables. It's having lots of fiber in the diet for men, that's close to 40 grams for women is probably close to the same thing. They say 30 grams to 40 grams of fiber in the diet. It's a lot of fiber. cutting back on red meat cutting back in calories, not allowing your body weight to fluctuate too much in terms of obesity, exercising, even if you're overweight exercising independent of that really will reduce the risk a little bit, all these things reduce the risk of inflammation in your body and inflammation seems to drive cancer.

People used to think that weight was just a cosmetic thing. It turns out it's not you know, fatty tissue is hormonally active, it does produce many inflammatory mediators in your body that do promote risk of several diseases, including cancer and colorectal cancer. So you know, keeping the weight down, watching the alcohol intake, really keeping the alcohol intake to zero or very mild amount of alcohol, meaning, when people say I drink occasionally, that really should mean occasionally, like I drink in New Year's and I have a glass of wine on Christmas Eve, it shouldn't mean that I drink occasionally every Thursday, Friday, Saturday, and sometimes Sunday, like that's not occasional drinking. So it does increase the risk quite a bit.

Smoking, as we know, is bad for you, and increase the risk of colon cancer. So not doing all those toxic things and then adding just people like the Mediterranean diet, it's probably the best cancer prevention diet. It's eating, eating lots of whole foods, watching out for the all the processed junk food that we eat in our society, eating healthy fats. There's plenty of information on the internet. I'm no dietician by any means, but a lot of times, if you look at the food, you know, it's not healthy for you. It's not healthy for you. So just, you're making a choice at that point. And you have to just build these patterns into your life.

In terms of prevention, you know, in terms of like actual prevention of colorectal cancer, and people who have genetic syndromes, there is a role of what's called chemo prophylaxis, meaning taking something to help prevent cancer. And the big thing that's been studied there is aspirin. You know, aspirin use does seem to reduce the risk of colon cancer and colorectal polyps as well, which is great. And you have to balance that with the side effects or the adverse effects of aspirin, which are not insignificant, even just a full dose aspirin every day has a significant risk of causing gastritis, which is stomach inflammation causing ulcers, causing bleeding, including bleeding in the brain and other weird stuff like that, allergic reactions, etc. So that's a relatively low risk. And most people tolerate aspirin just fine. People have studied using doses of aspirin up to 600 milligrams a day, which is about two, you know, full strength aspirin a little less than that. That's a pretty decent risk. A lot of people suggest taking the one 325 milligram aspirin a day to reduce your risk. But even people who take the baby aspirin, the 81 milligram of aspirin have a slightly decreased risk of colon polyps and colon cancer. And that actually holds true for the other end said medicines. So naparosin and ibuprofen, motrin, etc. But those are a little more gut toxic. So we don't advise people to take those. And that's an individual to say I'm not telling people to take aspirin in general, but that's something you can actually bring up with your doctor if you do have a genetic syndrome or if you've had colon cancer, it's an individualized decision based on your bleeding risk and your risk of getting cancer if you want to take aspirin. And that can cut it down a significant percent, it's up to 35%. They say it cuts down the risk of cancer, which is pretty amazing, but not for everybody. And it's still smaller, you know, small studies, so not, not super well defined. Yeah, and just getting screened, you know, you can't live in a bubble. So you have to do the healthy living things that you can do, you try to control your diet, and avoid toxic behaviors. And after that, it's just about getting screened.

SARA: Yeah, yeah, absolutely. Those are very helpful tips. And again, they're not insurmountable, right? These are things that we can do to minimize our risk within reason. So, okay, let's talk about the role of the "Real GI Doctor Show". Can you fill us in on your podcast? It's an amazing resource for patients. Briefly kind of fill us in on what your goal is for the show and how it's going and some upcoming topics that you're particularly excited about.

Dr. Gandolfo: Sure. So I started this podcast, I always was a fan of podcasts, I listened to a bunch of podcasts. And I can, as you can tell, I like to talk until I can't think of anything to talk about, it's a it's a problem I have. So it's almost like an outlet for me. I like to educate people about this stuff, because it's, I don't have like an hour to talk to every patient about stuff like this. But I do have an hour to talk to 1000s of people at once about this. And I think it's pretty cool. So it's a great platform for that. I just decided to do it.

And like anything else, if you think about it long enough, you either do it or you don't do it, I decided to do it, I'm going to do it for a year and see what happens. So how far am I into it? I don't even know almost a year at this point, maybe not maybe like eight months, nine months, but it's, it's going okay. It's a lot of work, I enjoy it. I have a little studio space up here. And the point of it is just it's really just educating people about these topics. And lots of people have these are all gastroenterology in general has a lot of sensitive topics. Lots of people don't feel comfortable asking or getting the information from their doctors or there's not awareness, whatever it is. So I think it's cool that people come here and maybe I'll touch in there on their topic.

And I take questions, which is great patients send me questions. Sometimes I recognize the voices sometimes the random listeners I don't know and they send me these these topics to answer and I try to answer them on the show too, which is pretty neat. So where do I see it going? I don't know, I don't know where it's going to go. It's going to be something that I do until it becomes too burdensome. If I if I feel like people don't really like it or don't care about it as much, I'll probably shut it down. But I don't think it's going to happen because I like it and it's growing and people seem to be writing more and more stuff to me about it. So it was a cool experiment. And I think I'm going to stick with it for now.

SARA: That's awesome. I think you should. It's been very helpful for me as well. So appreciate you. Thank you. All right. Well, before we wrap up, do you have any parting words of advice or any sentiments that you'd like to share with the audience? And then I'd love for you to share where people can find you how to follow your work and to tune into your podcast.

Dr. Gandolfo: Sure. So my parting sentiments really would just be if you think something's wrong, you know, if you have a if you have a genetic syndrome or not, you know, colorectal cancer is really common. So if you think something's wrong, talk to your doctor about it. And if they don't, if they blow you off or they don't take you seriously, go somewhere else. Someone will find, you know, what's going on and will and will take you seriously.

And, you know, if you're over the age of 45 is a no brainer, you just get a colonoscopy. You'll know if something's going on. If you are a young person, you know, the younger people, 30s who are becoming more and more at risk for colorectal cancer. The tragedy is that it's often missed because their complaints aren't taken seriously. It's called that doctors will tell them they have irritable bowel syndrome or something like that. And stuff gets delayed for months, years, and then they find out they have cancer.

So I think if you know something's wrong, a lot of people just intrinsically, they know something's wrong and don't take someone's word for it if you don't get, you know, what you need, basically. So be your best advocate is my advice.

And to find out about the real GI Doc show on social media, you can use the handle @realgidoc pretty much everywhere. And you can find the podcast on all the podcast players. It's the same thing - The Real GI Doctor show. And I have YouTube now I'm doing some YouTube videos. It's kind of cool. I got some, some good prep videos on YouTube.

So people like those, but a lot of people find me on those, which is pretty neat. And you can go to realGIdoc.com. You can see the episodes and you can submit a question. If you have a specific question, I can, there's an audio feature. So you can leave an audio question. I'll try to answer it on the show.

SARA: That's cool. All right. And then your practice in Long Island.

Dr. Gandolfo: Yes. So the practice it's called precision digestive care. It's my private practice. I started it in 2018. It's over in Huntington, New York, and you can just Google my name and you'll find it if you're in the area, but it's a, it's fun. I like having a private practice. It's, I was employed by a hospital for a couple of years and it was a thing for sure, but I like being on my own.

SARA: Yeah. Great. All righty. Well, Dr. Gandalfo, thank you so much for joining us today, sharing your expertise on colorectal cancer, genetic risk, and the importance of early screening. Your insights have really been invaluable to really help our audience break down barriers to prevention. And, and I think I feel like you've helped us empower the listeners to really take charge of their health. I think that's one thing I would hope people would get out of this episode. So thank you for being here.

Dr. Gandolfo: And thank you, Sara. It was a pleasure. This is my first guest appearance on a podcast. So it's a, it's a great experience and I really like what you're doing here. I'm glad that you reach out to me and I'll definitely be following you and your next guests as well. Cause I find the show great. So keep it up.

Dr. Gandolfo: Thank you. I really appreciated this. This was a really great experience and it was a lot of fun too.

So for those tuning in, remember March is Colon Cancer Awareness Month. March 22nd is Lynch Syndrome Awareness Day. So we'll be doing more activities around that. They are both powerful reminders that knowledge is key to early detection and prevention.

So if you're due for screening, you have family history of colorectal cancer. Now is the time to take action and talk to your doctor. Look at this episode as assigned to do those things.

You can find Dr. Gandelfeld's work at @realgi.com as well as the podcast - The Real GI Doctor Show for more expert insights on your digestive health. If you are in the Long Island area, please check them out at www.precisiondigestivecare.com.

So thanks for listening to the Positive Gene podcast until next time, stay informed, stay proactive, and remember you're not alone on this journey.

Resources Mentioned in This Episode:

• The Real GI Doctor Show with Fred Gandolfo, MD

• Precision Digestive Care (Dr. Gandolfo's practice in Long Island, NY)

• FORCE's Lynch Syndrome Facts, Resources and Support

• FORCE's Colon Cancer Genetics: Screening, Prevention & Treatment

• Colon Cancer Awareness Month

• Lynch Syndrome Awareness Day

Disclaimer:

This podcast is for informational purposes only and is not a substitute for professional medical advice. Always consult your healthcare provider with any questions about your health.

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