Living Downstream  Walking Upstream

Apr 24, 2012

How to Have a Colonoscopy

"Why don't people get screened? Sometimes the screening recommendations ... are confusing to patients."

~ Dr. James S. Goodwin, University of Texas

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It's April. I'm going to guess that you ignored the fact that March was National Colorectal Cancer Awareness Month. That's okay. In my opinion, March is the wrong season for colonoscopies anyway. June is much more preferable—more on why momentarily—and you still have time to pick up the phone and make a summer solstice appointment with your new gastroenterologist.

Everyone will be happy when you make that call, especially your new gastroenterologist, who undoubtedly—along with the whole gastroenterology community—bemoans the lack of universal compliance with current colorectal cancer screening guidelines; namely, that everyone over 50 should be screened, except for people at high risk, who should start screening at age 40 or earlier.

How do you know if you are at high risk? Well, certain medical conditions put you there. Also family history. If your parent, child, or sibling has had colon cancer, you are considered high risk. Or if you have a more distant relative who was diagnosed with colon cancer before age 60, you are at high risk. Or if you have two distant relatives diagnosed at any age with colon cancer, you land, once again—sorry—in the high-risk category.

Right away, you can see the problem. What if you are an only child and your dad died in a skiing accident in his 30s? Small families, limited data.

Or what if you and your sister are not on speaking terms regarding any topic whatsoever, let alone the status of her colorectal area?

Or what if your distant relatives haven't been to a doctor for 20 years? They might be walking around with colons full of tumors and nobody knows it yet.

Or what if, like me, you are adopted?

Now add this WTF finding: Family history plays only a modest role in the risk of disease. According to the best available data—from Sweden—13 percent of colon cancer patients have relatives who share their diagnosis; for the other 87 percent, nobody else in their family has the disease. (The statistics are similar for breast cancer.) And yet, the official guidelines entirely ignore environmental factors with demonstrable links to colon cancer, such as drinking chlorinated water or living near toxic waste sites.

None of these vexing problems would matter so much if colorectal cancer were not the second leading cause of cancer death in North America. But it is.

It's also one of the few cancers that grow in slow, predictable ways. An innocent polyp that has sprouted, mushroom-like, within the hollow log of your lower intestine requires many years to change into a deranged assassin with plans to set up branch offices in your liver. Those years of stepwise transformation mean that early detection -- eliminating the polyps before they become metastatic invaders -- makes a real difference. Done right, colon cancer screening is an act of colon cancer prevention.

Colon cancer is a leading killer. Colon cancer is highly preventable. The stakes are high.

But so is public confusion about screening guidelines. Determining what risk category you are in is one form of guesswork. Another is deciding what screening technique to choose. There are five of them: sigmoidoscopy, stool testing, barium enema, virtual colonoscopy, and real-life colonoscopy.

I'll just cut straight to the chase here: Unless you have some outstanding medical reason not to, suck it up and get a real-life colonoscopy. The other screening tools are not as good and some of them expose you to ionizing radiation, which is itself a carcinogen.

Here's where members of the gastroenterology community have the marketing all wrong. They presume that the general public is so squeamish about real-life colonoscopies that they offer inferior alternatives. If you do go the colonoscopy route, they shroud the whole affair in vague euphemisms and lots of drugs—the kind that sedate you to the point of amnesia and render you unable to drive, make important decisions, operate machinery, etc. You're certainly not going to be answering email for the rest of the day. Worker productivity takes a big hit from colonoscopies. The drugs mean that you lose a whole day of your life to a cancer screening procedure—albeit a really good screening procedure.

The drugs also mean that you have to find someone willing to serve as both your driver and your personal assistant during your sojourn in the outpatient recovery room, where you lie, doped up, under a big-screen TV wondering how to unwrap the straw for the ginger ale that the nice nurse just brought. Your straw-unwrapping chaperone will also have to take time off from work. And you'll have to find a babysitter for your 8-year-old and someone to make sure your teenager makes it to play practice and back.

And this all comes on the heels of the previous laxative-filled day, during which you were prepping for the procedure.

There may indeed be a subpopulation of people in their 40s and 50s that is truly horror-struck by the indignities of a colonoscopy. But, based on nothing but a few casual interviews with people my own age, I have come to the opinion that by the time one is middle-aged—and has logged some experience with root canals, back spasms, childbirth, mammograms, menopause, and prostate exams—it's not squeamishness that prevents us from making the necessary phone call.

It's lack of time.

So here's my technique, which I offer not as a medical doctor (which I am not) but as a cancer survivor and a busy working mother, age 52, who has undergone, at last count, nine colonoscopies, at least one of which almost certainly saved my life. (By way of explanation, Google "Lynch syndrome" and "adoptee.")

The centerpiece of my method: I skip the drugs.

Here's how to do it. Make friends with the scheduling nurse at the gastroenterologist's office. Ask for a colonoscopy appointment for first thing on Monday morning (this should be really early, like 7 a.m.). Then you can use Sunday as your prep day. I like the month of June for colonoscopies because you don't have to drive to the hospital in the dark. Also, fasting is easier when it's warm outside.

And you will be fasting. The pages of instructions you receive from the gastroenterologist's office talk about the clear liquid diet you'll be enjoying on the day prior to your procedure and they give a long list of permitted and prohibited food items. Ignore all that. Just fast. All you need is black coffee, some teas of different flavors, and a few bottles of coconut water, which is refreshing and good for your electrolyte balance (not coconut milk, which is not a clear liquid). Don't bother purchasing special things like white grape juice. It's too sweet on an empty stomach; canned chicken broth is too salty.

Here are a couple special things you will need: minty mouthwash, unscented baby wipes, and three or four good magazines. I prefer The Economist for colonoscopy nights.

In the evening of the fasting day, you start the clean-out. It is really important not to improvise here. Follow the instructions exactly. The current protocols from my gastroenterologist involve pouring a whole bottle of Miralax into a gallon of Gatorade, which you then drink throughout the evening according to a strictly prescribed, x-number of fluid ounces per y-number of minutes schedule.

It won't surprise you to hear that a Gatorade-laxative cocktail is remotely palatable only if you keep it cold. It's best to measure everything out in advance and line up all your glasses of lemon-lime-with-a-surprise-twist on the middle shelf of the fridge. Then set the kitchen timer to keep yourself on track. After downing each glassful, swish with some minty mouthwash, which cuts the aftertaste, and then sip some tea.

For this part, it helps to have a teakettle going and a warm bath drawn. When you push this amount of cold liquid through your body, your core temperature drops. By the last couple of glasses, I always have the shaking chills.

Accept the fact that you will never voluntarily drink Gatorade again. A small price to pay for not dying of colon cancer.

Once the drama begins in earnest, retreat into the bathroom with your good magazines. Just stay in there. You can get in and out of the bath, as needed to warm up. You will thank me for the baby wipe suggestion. After things wind down, sleep for a few hours. You will have at least one fascinating dream. Sadly, you will have to get up before dawn so that you can add insult to injury and drink more Gatorade laxative—per the gastroenterological protocols—at some specified time interval before your departure to the hospital. This second round of laxative is the eye of needle. You will hate this part. But soon enough, you'll have finished off all the glasses of vileness. The gray light of a June morning will arrive, the birds will start to sing, and you can pet your dog and have a little black coffee.

Since you are foregoing the drugs, you can drive yourself, unescorted, to the outpatient surgical entrance.

You'll be lying on your side. Ask for an extra blanket and a pillow to place between your knees.

Chat up the attending nurse. Ask lots of questions about her kids. Keep this up (verbal anesthesia) throughout the whole procedure, which will last a half hour or so. Your colon is about five feet long and is draped around your small intestines and up and over your liver like a big sausage casing. The scope goes up the whole length of it. There are four serious curves. When the leading end of the scope is bending around each one, you will experience cramps. Stop talking to the nurse and just breathe for a while. Forget everything you have heard about the mind-body connection. For now, René Descartes rules: Mind. Body. Split. Keep your head north of the split. The cramps last only a couple of minutes and, just when you think they might become unbearable, they subside.

Otherwise, the procedure is tedious and unpleasant, but not excruciating. If you've ever been pregnant, some of the sensations are like a baby kicking.

The doctor will be looking at the large-screen monitor where the journey though the pink tube of your beautiful, empty colon is displayed like an episode of Nova on PBS. You can watch or not watch. I choose not to watch.

When it's all done, you get to stand up, put your street clothes on, and stride out the door. You'll feel very thin and very proud of yourself. You may not even be late for work.

If the gastroenterologist found nothing, you are completely free. You may not have to come back for 10 years. If he or she found something (snipping out polyps doesn't hurt, by the way; the lining of the colon lacks nerve endings), you'll have to wait five to 10 days for the biopsy results to come back from the lab. That's a drag. But it will be with the knowledge that, whatever it is, it's out of you now, and finding it sooner is much, much better than finding it later. You can't always say the same for the suspicious spot on the mammogram.

If you've thought ahead, you'll have some treats waiting in your car. A little yogurt, maybe. A thermos of milky coffee. A cookie. Or if it is June—say it's the first day of summer—you can drive out to the nearest u-pick strawberry field. Walk right out into the sun-dazed rows, still wet with dew. Break your fast with the reddest berry you can find.

Eat your fill. Reinhabit your body. Give thanks. Praise the day.

© Sandra Steingraber, 2012


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About Sandra

Ecologist, author, and cancer survivor Sandra Steingraber, Ph.D. is an internationally recognized authority on the environmental links to cancer and reproductive health.

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