Unraveling Confusion Around Colonoscopy with Dr. Sherief Shawki

In this episode, Debra talks with MedStar Health colorectal surgeon Dr. Sherief Shawki about survey results which reveal many Americans are confused about when to have a colonoscopy. This discussion covers the rise in colorectal cancer diagnoses in younger adults and the impact that’s had on the guidelines for routine screenings. Dr. Shawki explains how colorectal cancer develops, and how colonoscopy can actually prevent cancer by identifying and removing these growths early.

The conversation also covers how genetics and family history can affect screening timelines, and what symptoms should never be ignored. Dr. Shawki walks listeners through what happens during a colonoscopy, from the preparation process to the procedure itself, and addresses common concerns that often cause people to delay screening.

MedStar Health DocTalk aims to make complex medical topics easier to understand by bringing together experienced physicians who share their expertise in a clear, conversational way. Whether you’re interested in learning about cancer prevention, new medical technologies, or advances in treatment and surgery, this podcast offers reliable information from trusted experts. 

Learn more about colorectal surgery at MedStar Health:
https://www.medstarhealth.org/services/colorectal-surgery

To make an appointment:
443-777-2475

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Email: DocTalk@medstar.net

For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.

Transcript

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Comprehensive, relevant, and insightful conversations about health and medicine happen here when MedStar Health, dog talk. These are real conversations with physician experts from around the largest healthcare system in the Maryland, DC region. Sadly, it seems most of us have been impacted by a diagnosis of colorectal cancer. It has touched my own family. Recently, the conversation has grown louder as several well-known actors have died from colorectal cancer, including Chadwick Bozeman who died at just 43, and Dawson's Creek star James Vanderbeek, who died at 48. Earlier this year, actress Katherine O'Hara, known to many as the beloved mom and home alone also died from complications related to colorectal cancer. It used to be considered an older person's disease when routine screenings weren't even covered by insurance before the age of 50, but that's changed. A national survey commissioned by MedStar Health found that more than 75% of Americans are unsure when or how often to get a colonoscopy screening. Even more concerning, more than a third of eligible adults say they've skipped screening altogether. And this comes on the heels of the American Cancer that colon cancer is now the leading cause of cancer deaths among people under 50. The facts are clear. Colorectal cancer is the third most commonly diagnosed cancer in the US, and the incidence of diagnosis in people under 50 has roughly doubled in the last 30 years. It's never been more important to remove all doubt about who should get a colonoscopy and when. Joining us to clear up the confusion is MedStar Health colorectal surgeon, Dr. Sharif Shawke, and I'm your host, Deborah Schindler. Dr. Shalke, thank you for being here today. Thank you very much, Deborah, for hosting me. I'm looking forward for a good session trying to answer some of the questions, clarify some of the misconceptions, and hopefully we'll deliver a good information for the audience. Let's start with the big picture. What is colorectal cancer? That's a very good question to start with so people can understand ultimately what we want to achieve. So I'm going to even back up one step. Let's just say in the human body, there are three types of cells, labile cell, stable cell, and permanent cell. So permanent cell, for example, like the nerve cells, they don't replicate what you are born with, you stay with. The stable cell you are born with, you stay with, the only regenerate when is needed. When there is injury, when there is something happened, and they need to regenerate. Now this will lead us to the labile cell, which are cells who are continuously replicating like your skin, like your hair, like your GI tract. If something that's replicating continuously, this means that during replication, things may go wrong. In our colon example, the continuous replication may result into an overgrowth, also known as a polyp. That overgrowth is not cancer yet, but if it is left to grow, it will eventually become cancer. So a colon cancer is a transformation in the normal lining of the colon that usually starts as precancerous growth that is left in place, unremoved or untreated. It will become cancer. Do all colorectal cancers start as that precancerous polyp or this growth? Can they come about another way? For the most extent, yes. They start as precancerous lesions, polyps, and then they become malignancy or cancerous. Now, the difference in types of cancers, if it's sporadic versus genetic and even the type of genetic itself is the duration, how fast or how slow the precancer growth, AKA polyp, would become malignant. For example, a genetic syndrome will have this adenoma, the polyp, another name for it, adenoma to carcinoma transformation polyp to malignancy in one to two years. The other extreme in this sporadic, which it can happen to anybody, not people who have genetic predisposition to cancer, it can take up to seven, eight, or even 10 years. So in theory, the process that takes years gives us plenty of time to interrupt that cycle process, stop the growth with screenings. Excellent question. Based on knowing the background of the person, this will enable us to provide the right guidelines and the right guidance to how to prevent polyps from becoming cancerous because the good news here, if you can stop the cycle of transforming the polyp to a cancer malignant growth, then you will not have that cancer. And that's the positive message we are trying to deliver to the people that with one test, you can prevent cancer. And that's where the colonoscopy becomes so powerful because if it's found early enough, it could be removed before it has a chance to develop into cancer, and that's clear and understood. But I think where the confusion sometimes happens is maybe they don't know they're predisposed to this cancer because of genetics. Maybe they don't know that they had a family member who had it. If they do know, what's your recommendation? Another good point, Deborah. So let's talk in general about how we look at screening colonoscopy in relation to family history versus no family history. Okay. So in the old times, it used to be, as you said, an old age disease. Therefore, people would start screening colonoscopy everybody at age of 50 without genetic predisposition, without family history, just a person who had no family history. But we have realized that a younger age had been getting colon cancer more frequently compared to the last millennia, and it's almost doubled and it's going to triple. Therefore, the screening age had dropped down to 45. Now, let's say somebody has a first degree family member with colon cancer that was picked at age of 54. If you look at what we were saying, this means that this person had been having a polyp for eight years ago, at least, and has been growing silently until it was detected on a colonoscopy when the patient started having blood in the stool or bleeding per ectum. Therefore, that prompted colonoscopy and it found a malignancy. If that colonoscopy was done eight years ago, it could have basically prevented that situation from happening. Therefore, the guidelines dropped the age of screening colonoscopy from 50 to 45. Now, that person who had cancer at 54, now their kids should start having screening colonoscopy 10 years before the age of diagnosis, which means 44. What about siblings? Siblings, if it's not genetic predisposition, So right now, everybody will go at 45. If there is any alarming signs, bowel habit changes, bleeding, straining, the sense of defecation that doesn't translate into a real bowel movement, all of these are signs of space occupying lesion and there is something wrong, which should prompt going to your primary care physician and should prompt doing screening colonoscopy. In people with genetic predispositions, we know that these genes, what do they mean in terms of the genetic anomaly? And what does this translate to the age at which screening colonoscopy would become right? For example, familiar adenomatous polyposis, people would start screening at the age of 11 years. So the kids of a person with familiar adenomatospoliposis known as FAP, they would start at age of 10 or 11. A person with something called Lynch syndrome, they would start between age of 20 and 25. The former will do this colonoscopy every year. The latter will do every year to two years, depending on how much burden of polyps are there. So we know the genetic syndromes, we know how to deal with them. We take care of those families, we educate them, we take care of their offsprings and their kids, and they are usually more engaged and more involved. Are they usually a faster growing cancer. When. They're younger like that? Yes. Or. Genetically predisposed? They are genetically disposed. We know for FAP that by the age of 40, they will get colon cancer. That's why they will have something called prophylactic colectomy. So at some point we prophylactically remove their colon and rectum to avoid having cancer. Wow. And for Lynch syndrome, they have, as we talked before, the adenoma to carcinoma progression, the polyp to cancer transformation. They have a very fast adenoma to carcinoma duration. Despite what I've told you about the genetic syndromes, they occupy about five to 6% of all colon cancer. So not every young onset colorectal cancer is considered genetically predisposed. And it is what makes colon cancer different from many is possibly prevented. With. The screenings. Exactly. Because in order for someone, as I said, in order for someone to develop cancer, they have to have growth. Now, that growth could be treated if it is picked up early and could be removed and we can stop the cycle there. Therefore, the colonoscopy is a very important tool to identify, diagnose, and to treat by removing the precancerous growth, blocking this cycle. Now, there is something I must say to explain for the audience, why do we do colonoscopy every 10 years? So you will hear somebody saying, "Oh, I get myicolonoscopy every five years," or,"I get micolonoscopy every one to two years, or I get macolonoscopy every three," and so forth. So that was the importance of the introduction I gave earlier, because as we said, here are the facts to conclude an information. It takes time for the polyp, the precancerous growth to become malignant. That time could be eight to 10 years in the sporadic normal human being. It could be shorter in somebody who has a first degree relative with colon cancer, because we know these people are at higher risk. It could be even shorter if somebody who just has colon or their colon is a polyp former. It could be even shorter in somebody who is genetically predisposed, and it could be as short as in someone who has chronic longstanding inflammation like inflammatory bowel disease. What does this mean for the audience, simply speaking? So if somebody gets a colonoscopy, they are clear, which means they have no polyps. They are good to be seen in eight to 10 years. Why did we say this? Remember, polyps can form continuously. The colon has labile cells. They replicate continuously, therefore they can grow abnormally at any point. All the information I provided is layered. Therefore, if you are clear now, this doesn't mean that you're clear forever. This means you're clear now, but tomorrow you may start having another polyp. How long this polyp will take to become cancer? About eight to 10 years. Therefore, you are due for another screening colonoscopy If you have polyps, depending on the type of the polyp, if that type of polyp is rapidly growing to malignancy, then you cannot do it in eight years because you can have cancer that will grow in five years. Therefore, we tell you, no, you have to come in five years because you have that type of polyp that is risky to become cancer sooner than later. Okay. What if I have a genetic syndrome? Well, depending on the genetic syndrome, the adenoma to carcinoma sequence is very fast. Therefore, you're going to come every year. What if I have a chronic longstanding inflammatory process condition such as inflammatory bowel disease? Well, we know after 10 years of inflammation, people tend to have an extra percentage of risk to develop cancer. So if somebody with chronic ulcerative colitis and these patients know that very well, after 10 to 15 years of the disease, they will start having colonoscopy every one to two years, because their longstanding inflammation results into provoking malignant transformation as another external factor. So for each person and each situation, there are guidelines. The bottom line for the audience is don't get noises from what other people are telling you. You just need to focus on your own health. Do your first colonoscopy and let your healthcare provider take care of the rest. Get a GI specialist, right? A gastroenterologist. And if they have inflammatory bowel disease, you'd think they were already being treated by someone. Absolutely. That's why I said- You would be. Making these recommendations. That's why I said these people already know. I'm just trying to explain for the audience who don't know this. Why would you hear different durations and different frequency of colonoscopy because people conditions are different? They are different. Well, look, since the mid 1990s, diagnosis in people under 50 have been rising from about one to 2% every year, and the number of younger patients has just about doubled. We've established that. So among adults ages 20 to 39, the incidence has been rising about 2% a year. That, of course, created the need to change when the colonoscopy is a standard screening from age 50 to age 45. I want to be clear about that and underscore that not seeing a gastroenterologist and they're not already maybe they're still thinking,"I have until I'm 50." I just want to underscore that going into this podcast, that routine screenings start at 45. Now, to think of someone being 20 and getting a diagnosis of colorectal cancer is inconceivable. What's the youngest age that you've treated, would you say? It's sad story. The patient was not even 20 years old. Oh my goodness. And it was delayed presentation and it was already metastasized. Unfortunately, they didn't make it. And I have been seeing more often in 30s and in 20s, over the last few years. So sidestepping the issue of genetics for a moment, is there anything maybe research wise that supports why that's happening? And is there anything that we can do to prevent colorectal cancer such as our diet or minimize the risk for it? That's a very good question and a slowed question. So on the scientific side, there are many studies underway trying to identify why is it happening in the younger population? What led to that shift or what led to that rising incidence in the younger population? But I have a very simple opinion, and this is my humble opinion. Usually human beings starts to do new things, and then you see the impact of this in two, three decades down the road. So something must have happened. 20, 30, 40 years ago, we changed something in the diet. We consumed something in a processed diet. Something happened that its effect on the human genome is basically had been showing over the past decade when we have been noticing the increase in young onset colon and rectal cancer. As for how to prevent it, as much as I can say, there are known factors that are unhealthy and they lead to diseases. Therefore, moderation in general is a key. For example, you will find smoking involved in cardiac disease, in lung cancer, and with other type of cancers as well. You will find the red meat involved in obesity or fat related diseases, blood vessel diseases, as well as colon cancer. Therefore, my advice to the audience is this. Adopt healthy lifestyle. You don't have to cut off anything, but moderation is a key. Not too many potato chips or ... I have to tell you, I like potato chips, but I stopped binging on them long time ago. I like them too. What about this idea of an aspirin a day? I read that as an anti-inflammatory that some people believe in aspirin a day keeps the GI away. Is there any truth to that? It's unconfirmed. In my mind, it's unconfirmed yet. So back to the MedStar Health Survey, which resulted from questioning 1,000 people. Four in 10 people believed screening after the age of 45 is only necessary if there's a family history of colon cancer. I think we've already addressed that, but true or false? False. Right. Why should someone with no family history still get screened? And how often? Perfect. So this is a good question now to examine the audience for what we have been talking about. Someone without family history, number one, do they need screening colonoscopy or no? Remember, the GI tract has a type of cell that replicates continuously. Therefore, an overgrowth can happen anytime and that overgrowth can transform to cancer. So the answer is yes, they should get screened colonoscopy. At what age? Right now, at 45. And it could be younger if there are alarming signs such as blood in the stool, bleeding per rectum, constipation that is just not explained. Change in bowel habits, feeling the urge to defecate, but really nothing come out. All these are signs of space occupying mass, like a tumor or a large polyp. A large polyp can harbor pre-malignant cancer and it's not considered cancer yet, and therefore it can be basically removed by colonoscopy. Well, that's interesting too that another concern that was revealed in the survey is that only 13% of respondents couldn't identify all the symptoms of colorectal cancer. And you just went through a full list of them, but we know that people who show up with colon cancer or colorectal cancer who had no symptoms. Thank you for saying that, Deborah, because it's a slow growing tumor. So there is a time that it will be silent. I have many of my patients who come and they are curious and they say, "Doc, how long have I been carrying this tumor?" And I say,"At least eight to 10 years." And you should see the shock look on their face, and I feel sorry to tell them that, but they can't believe it. They are in denial. I have been living with cancer for that time. Yes, you are. When you find a polyp or a cancerous tumor while performing a colonoscopy, is it usually one? This is a very good question. I'm going to answer this in two dimensions. Number one, which is a direct one, yes, you can find one or you can find as many as two, three, four, five. Now, if you find more than 10, then we start thinking of polyposis syndromes, something genetically predisposed to result into that colon to form way larger numbers of polyps. Okay? The other thing that I want to tackle is this. We are all perfectly imperfect. So colonoscopy is very sensitive when it's done by the specialist. That's why you said, Deborah, in the beginning, you need a gastroenterologist to do with somebody who knows what they are doing and how they do it and they do it up to quality indicators and metrics. However, we know there is something called misrate. What does this mean? This means that I can do colonoscopy in a patient and I can detect three polyps. Now you are better than me. You can do a colonoscopy for the same patient and you can detect five polyps, which means I miss two. So we know that we have an acceptable miss rate. I can do colonoscopy and I can miss a polyp. That's a forgivable miss. But if I miss three or four, that's unforgivable miss and it should not happen. So if somebody has colonoscopy or their colonoscopy is normal, that's very good, up to 90%, 90 plus percent. And that's why we say you have to come back in eight years, because if there is something missed, it will take that duration to be discovered early at least. And that's why with somebody with longstanding inflammatory conditions or genetic predisposition, we do that colonoscopy every one to two year because we know that duration from adenoma to carcinoma is shorter, but factoring also the miss rate. Let's say what if we missed one? And that's why we do it every one to two years to detect the lesion early and to compensate for any missed polyps from the prior colonoscopy. Would you repeat the name of that condition that you just identified where someone has a lot of polyps? It's called polyposis syndrome. And does that significantly predispose someone who has that to getting colon cancer? Yes. So going back to the genetic disease I told you about, for example, familial adenomatous polyposis, juvenile polyposis syndromes. As we said before, it starts by growth that's called polyp. The term osis in medicine indicates the presence of numerous polyps. So polyposis means there are so many polyps that are existing in the colon. So many polyps, meaning so many growth where therefore there are one, it takes only one of those polyps to become cancer. And you cannot really detect it just by looking at it- Not by the size. In the colonoscopy. A bigger polyp means closer to being a cancer? No? So very smart question, Deborah. So there are something called advanced polyps. Advanced polyps, meaning it's a polyp that's closer to become a cancer. And the advanced features are size, shape, configuration, and histology, the type of cells. So size above two is advanced. Shape and configuration, flat polyps, the polyp could have a neck called pedunculated polyps, or could be just stunt flat on the colon wall. They call systele polyps. So these are more risky. And then the type of histology. If they have more abnormal cells, this means they are more closer to become cancer. But you can't just lance at that. I mean, I assume that you're able to identify them during the colonoscopy. Maybe without the biopsy, do you come out and say, "Yeah, I think that's likely to be cancer. We haven't done the biopsy yet, but I'm pretty sure that that's going to come back. As. Cancer.". Yes. An experienced gastroenterologist or colorectal surgeons routinely, they have enough experience to suspect a malignant lesion in colonic growth. There are also other criteria and features that they can apply on the lesion that they can know by which they can know if the tumor is high risk to harbor malignant cells or no. The gastroenterologists now have more advanced techniques. So I want to assure the audience if there is a polyp or even a larger polyp that had been found, we now do organ preservation endoscopic advanced techniques where the advanced endoscopist can go in and shave that large polyp from the colonic wall, take it out, and the person does not need to have their colon out. If it was pre-malignant, but big polyp. Okay. But if it is malignant, there's a resection of the colon. Then the best course of action is to resect segment of the colon and put the colon back together all in one surgery and no bag is needed. Okay. So many people do feel nervous about getting a colonoscopy and in spite of the screening itself, it's really the prep that people most complain about. Let's go through the PrEP process. Is there anything that you can share that suggests that the PrEP process has improved from maybe when the last time someone did one? Well, PrEP is PrEP. The concept is if you're going to do a colonoscopy, you want to do it successfully and you want to do the bowel prep once. You don't want to do a half job in getting your colon cleaned and cleansed, and then the colonoscopist or the endoscopist cannot see clearly the colonic mucosa due to fecal material residue in your colon. So therefore I say, if you're going to do the colonoscopy, take the bowel prep seriously. Now, the concept of the bowel prep is you're giving a material that it will result into water and fluid being in the colon to wash all the stool out. Therefore, it is taken with lots of fluid intake to avoid dehydration and to avoid electrolyte imbalance. Regardless of the type of prep you are using, this is the concept. You want to put lots of water in your colon to remove any fecal material residue so the endoscopy can have a clear picture and minimize the misrate we talked about before. This could be in form of high salt compounds, which is going to draw water in your colon, or it could be high sugar based compound like the polyethylene lycol, which is also going to draw water, but you take it with water. So the bowel prep, Deborah, unfortunately, is the wishful thinking. The bowel prep is a bowel prep and we are basically inducing diarrhea for a short period of time to clean any fecal material residue of the cone. But I have heard people describe their experiences differently. Some of them are using pills and not having to drink a gallon of water. Some of them are using Gatorade. They're all different. Is there something that you can share with us that would suggest this might be an easier way to go, that your patients come back and they say,"This wasn't so bad. I didn't have a problem getting all that down.". It's a good point. As I said, there are different types of compounds used for bowel prep. There is the one that you drink a gallon of water with, and the pills and the other stuff is basically, it has more concentrated material like salts, but this also may impact your kidney function and it imbalance and dehydration. The concept of reducing the amount of fluid to be drank with the colonoscopy doesn't go unpunished too. As we said, there is a concept to remove the stool from the colon. We just need fluid to ... That's common sense. You need fluid to wash off the stool residue of the colonic wall. You can help your body by drinking water that can go into your GI tract and wash off that stool or alternatively, you can take the pill, which is basically a concentrate of salt that will use your own body fluid to get inside the GI tract with less oral intake compared to the gallon, and it's going to wash off the stool. So if you look at the second situation, yes, you are drinking less water, but that's on the expense of your own body water. Therefore, you are more susceptible to water imbalance or water shifts in your body and electrolyte imbalance in your body. I would not recommend somebody who is old age. I don't recommend somebody with kidney related diseases that would do that. So maybe that's why-. That type of bowel prep. And last but not least, when I had my two colonoscopies, I used the gallon and I will share with the audience, I just friended, meaning I did not look at it as a challenge, I looked I learned to look at as I'm going to, "Oh my God, I'm going to drink all All of this, no, I looked at it as I'm going to get good news tomorrow when my colonoscopy come back normal or when they found a polyp and they take it out. And indeed they found advanced polyp in me and they took it out. Therefore, I have to make my colonoscopy in three years from now. Another good thing I'm going to share with the audience, when you do your bowel prep and you drink that fluid and you empty your colon, you will have the best feeling of your GI tract because you have got rid of so much weight that was causing inflammation in your GI tract and you will feel really good. I know. I need that. Yeah. A lot of these questions are coming from the heart. If this answer would be really good, I'll leave it up to you to say it or not say it, but this is really how I feel. Okay. So the prep is done and the person, the patient comes in. Walk us through what happens next when they have to come in for the colonoscopy. Take us through it step by step. Excellent. So the day before the colonoscopy, they but they were also not allowed to eat. They were allowed to drink. So they don't clean the colon and then there's another material coming on its way to becomes tool for the following day. So they are not allowed to eat. They only drink clear stuff. So the day of colonoscopy, the people go to the endoscopy suite. They are met with very friendly nurses. They know that this is their first time most likely. If it is the second or third time, then they usually know the drill. For the first timers, they meet them, they comfort them and they take them to the process. First, after they check in, they go to a room so they can change their clothes. After that, you will go into the endoscopy room where you meet the technician endoscopist. You will meet the technician nurse and the circulating nurse. The doctor will explain for you what they will do and how they will do it, and they will also explain for you that you will get sedation. Depending on the policy of that endoscopic suite, you can fall asleep or you can be in a twilight don't have a sleep. It doesn't really matter. You will be comfortable anyway. And that sedation is through an IV? Yes. Through an IV access, therefore you will get an IV line placed before the procedure. Once you sign the consent and you get your medication and you start falling asleep, they are lying on the left side and their both knees are bent upwards or the right knee is bent toward the chest and the left knee is not bent. It's in a position that allow the endoscopist to perform the procedure comfortably and also allow the person themselves to be lying comfortably. Usually the procedure starts with a gentle digital exam to make sure there is no tumor in the interrectal area, interrectal junction. And then the tip of the colonoscopy is introduced gently with good amount of lubrication to avoid any discomfort. Endoscopists navigate the colonoscopy through the colon until they meet their final destination, which is the junction between the small bowel and the colon, an area called the cecum. Once the endoscopist get the final destination there, the exam starts. The colon is examined while the colonoscopy or the outwards. While the endoscopist is retracting the colonoscope outwards, they start looking all around circumferentially in the colon surveying it. There are folds in the colon that acts like curtains. There could be hidden growth. So the endoscopist has to go through that, look to the right, look to the left, look up and look down to make sure there is nothing behind those walls. We call them like curtains because they look like a curtain. And when the endoscopist is retracting or retrieving the colonoscope outside, they have to go and look behind those curtains on each side to make sure there's no residual lesions there. And that's the concept behind the mist rate we talked about, because sometimes the polyp is so tiny and it's just growing that even with a head-on look at it, it may still not be visible for the endoscopist. Until they come back all the way to the rectum, in the rectum, they need to look upside down or look backwards on themselves to see the area is called retroflection. So the colon, instead of basically the scope, instead of basically looking forward, the endoscopist make the colon tube like a letter of J. So it looks on itself like a candy cane tip on the interrectal junction because it's one of the hidden areas. Once that is done and it's clear, the endoscopists adjust the position of the scope again, suction all the air out, and then they take the scope out. And the best part after that, that the patient or the person can go eat because they're usually hungry. So it's not an easy process to go through a colonoscopy. There's a lot of things that maybe people feel indignified about, or maybe they're just not comfortable with the whole idea of having to go through a prep. So what do you say to your patients who are really hesitant to schedule their first screening? What can other people say to their loved ones to ensure that they go and have that screening. Done?That's a very good point. I would say this, and I apologize if this would hurt some people, but I would say let's all close our eyes

and imagine it's 20: 35:47

30 and you are seeing me in the clinic and I'm telling you, I am so sorry to let you know that you have colon cancer, you'll have to get part of your colon out and you may need a bag. And unfortunately, there is nothing you can do about it to reverse the clock and to undo the cancer. We also need to make imaging studies to make sure the cancer did not spread to other organs in your body. How do you feel now? And imagine now I'm telling you, okay, open your eyes. Now we are back in 2026 and you can avoid that situation by doing your colonoscopy. Avoid the trauma and the burden to yourself, to your significant others, to your family, and to your beloved ones if you can only do the colonoscopy. I have to say that is powerful. That is a powerful message. I thank you for that. And thank you for helping us clear up the confusion around colorectal cancer screenings and why it's so important not to delay. The bottom line is simple. Colon cancer is one of the most preventable cancers Talk with your doctor about when you should begin your is right for you. And if you notice symptoms like blood in the stool or changes in your bowel habits or unexplained abdominal pain, don't ignore them, get checked. Early detection saves lives. Dr. Shawki, thank you so much. Thank. You Debra. It's been a pleasure and I'm looking forward for more educational podcasts for our patient and community. As am I. To make an appointment with Dr. Shawki or another colorectal surgeon in Central Maryland, call 443-77-2475. To learn more about our MedStar Health Colorectal Surgery Program or to find a colorectal surgeon in the Washington DC region, visit medstarhealth.org/services/colorectal-surgery.