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Interviewer: Colonoscopy has reduced deaths from colorectal cancer up to 70% but yet some people still don't have them done. Can they help you overcome some of the common barriers that people face to getting a colonoscopy next on The Scope.

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Interviewer: Dr. Kathleen Boynton is a gastroenterologist at University of Utah Health and colonoscopy is one of these instances where it's a really good tool for prevention but a lot of people still choose not to use it. What are the reasons and how can we overcome some of those barriers? Dr. Boynton, I guess there's five of them so let's just start with number one.

Dr. Boynton: I think it's probably fair to say that perhaps what we need to be doing as a medical establishment is doing a better job of informing patients about why we emphasize colonoscopy screening. We know that colonoscopy, as you mentioned, is effective at cancer prevention in up to 70%. In other words, your reduction and the likelihood of getting colon cancer is decreased by 70%.

Interviewer: Yeah, it's one of the most deadly cancers but yet, one of the most preventable but only if you get the colonoscopy.

Dr. Boynton: Right, right. And it's a tricky thing because most people assume that cancer causes symptoms but not necessarily and that's why we do screening. We recognize that for both breast and colon cancer for instance, you don't have symptoms. When you get symptoms is generally when the disease is advanced and your window for cure is gone. So when studies are done to look at how is colon cancer affected by getting a colonoscopy, we see that the decrease and likelihood is substantial.

Interviewer: So sometimes it can be a little overwhelming. As a patient, it feels like there's all these screenings and tests we have to take which is not necessarily always the case. However, colonoscopy is one of those that really we know is really effective at preventing a disease. So that's the first thing is a lot of people don't realize the importance. Number two, this is a common one I hear, the preparation is tough. You have to drink all sorts of stuff and it takes a day of preparation. Explain that a little bit.

Dr. Boynton: Yeah, well, I do not mean to sound as though I'm making the experience a trite one. I think it is a very difficult prep but in my mind, it's worth the investment. As difficult as it is, I think it's worth it to go through that experience for that reduction and risk. And keep in mind, the risk reduction, let's say it's 70% risk reduction, if I tell you you don't have to come back for 10 years, I'm telling you you have a 70% decline in your likelihood of colon cancer for the next 10 years. That's pretty profound.

Interviewer: Yeah, for a 12-hour, 24-hour investment of your time. Who wouldn't do that, right? The return on investment on that is really good. So the preparation can be tough for some people but the return on investment is really, really high and it's probably not as bad as a lot of people . . .

Dr. Boynton: Yeah, we get the gamut of experiences but I think it's fair to say we generally have a couple of patients everyday who say it's not nearly as bad as I thought it was going to be.

Interviewer: All right, number three, one of the barriers to people choosing to get a colonoscopy is just the fear of the unknown, like there's a lot of scary things involved with this, least of which is, "If I have cancer, I don't know that I want to know that I have it." So what about pain? I would imagine a lot of people fear that they don't know if it's painful or not.

Dr. Boynton: Yes, yes. My answer if patients ask me about the likelihood of pain, I generally say, "The possibility that's going to happen is very low that you're going to experience any discomfort at all." In very unusual circumstances if somebody has a complication related to the pain medication, we may back off, but that's decidedly an exception to the rule. Generally, it's painless to go through this.

Interviewer: And back to the main point. One of the biggest fears is, you know, that diagnosis can be kind of scary. Maybe I'd rather not know. Do you run in to that a lot?

Dr. Boynton: Yeah, and I can sympathize with that. I don't want to go to the dentist because I'm afraid I'm going to have something wrong.

Interviewer: Yeah, like a cavity which . . .

Dr. Boynton: Yes.

Interviewer: This is something quite a bit, a lot worse, right?

Dr. Boynton: Much. Very much so. But in this case, again, I get back to the idea of why we do this exam. Generally, when I find it on a scope, it's a curable lesion and many times, we can remove it at that time.

Interviewer: Don't even have to come back.

Dr. Boynton: Right. Even if it's an early cancer, we can take it out.

Interviewer: Reason number four, it can be a bit of an invasive experience and some people are afraid of that.

Dr. Boynton: Yes, yes.

Interviewer: What do you say to that?

Dr. Boynton: I think that is also in a sense related to that whole fear of the unknown. We've taken in breast cancer and colon cancer, we're kind of screening in very personal areas of the body and I think for a lot of patients, just this idea, this concept in their mind of what we're about to do, much less with people you've never met before, is pretty daunting. At the same time, I can say with great assurance that, at least here, we are very aware of how complicated this is and very sympathetic with how invasive this seems. We're investigating a very private area of the body, how is this going to happen in a way that's not awkward or embarrassing? So the link that we've provided on our website is actually a reenactment of going through the prep and the colonoscopy, and hopefully it serves to reassure people that we are very aware of the hesitations people have about this.

Interviewer: And then finally, the cost. There can be some confusion sometimes as to what the insurance might cover, what it might not cover for those without insurance, how they pay for it so . . .

Dr. Boynton: Right. So the university will investigate this issue on their own as well as you can call your insurance company and find out what your limitations are. We are very happy to work with people that have certain limitations provided by their insurance. Generally, screening is covered on insurance.

Interviewer: And they're getting . . . even if you might have to pay a little bit more, as far as all the tests that are out there in the world, this is really one that could make a difference in the quality of your life, not only just the longevity but the quality of it.

Dr. Boynton: Yes. The co-pay for a colonoscopy is much less than the co-pay for colon cancer.

Interviewer: Right, right. So we covered, I think, a lot of barriers and of course, if people have any other personal barriers, what should they do at that point?

Dr. Boynton: When we call to schedule patients, we have a dedicated call team that schedules only these. They can leave a message with the call center that's scheduling individuals and let them know what their concerns are and we do get that message and we're very happy to work with anyone if it makes their experience easier.

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Dr. Miller: Bacteria that live with us in our gut, the microbiome. We're going to talk about that next on Scope Radio.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Dr. Miller: Hi. I'm here with Dr. Kathleen Boynton. She is a professor in the department of medicine, and she is a specialist in gastroenterology, diseases of the gut.
We're here today to talk about the microbiome. Kathleen, tell us about the microbiome. My understanding is that we have billions and billions of bacteria living with us, and we need them to live with us as they need us. We work in a symbiotic relationship, and when those become disturbed and the relationship between the bacteria that live normally in our gut is disturbed, that can create problems.

Dr. Boynton: Yeah, this is sort of the topic where I think where do I start with the story. We've known for a long period of time that we have bacteria in our gut. It was traditionally thought that these bacteria just helped with the breakdown of food and that they prevented more damaging bacteria from inhabiting the gut. Currently, we recognize that they do so much more. They train our immune system how to react to infection throughout the body.

Dr. Miller: So, it's not just that these bacteria create that unsavory gas that everybody talks about.

Dr. Boynton: That's right.

Dr. Miller: There's a lot more to it than that.

Dr. Boynton: Yes. They can produce a whole host of chemicals that may work in our best interest or may lead to most of the common diseases that we're seeing in our clinics these days.

Dr. Miller: We've adapted to bacteria as they have to us for millions of years. I mean they're in all animal guts. Some of our listeners might think that bacteria in our colon seems strange. In fact, that's quite normal. What is abnormal is a change in the concentration of this bacteria or introduction of other pathogenic or disease causing bacteria into that biome. Would that be right?

Dr. Boynton: That's correct.

Dr. Miller: Your area of study seems to be much more focused on new ideas about the microbiome and what that's doing for us. When that's disturbed, there could be far reaching problems that are related. Maybe you could talk about that a little bit.

Dr. Boynton: Yes. That's exactly correct. What is so surprising to us is that a disruption or disturbance in the microbiome can literally create diseases that are remote from the gut. There are studies on diabetes that talk about it's associated with a disturbance in the microbiome, or autism, or Parkinson's. Traditionally, we had thought that those were two independent organs that never spoke to each other.

Dr. Miller: These are concepts that we still need to prove, right, those associations...

Dr. Boynton: That is correct, yes.

Dr. Miller: ...epidemiologic or population based associations. I would suspect that there's still work that needs to be done in that area.

Dr. Boynton: Oh, much work that needs to be done. The fundamental issues are not even addressed. We don't know what those bacteria are. We don't know how many of them have any role in our health and well being. As general concepts, we can determine that some people have a reduction in the diversity of the bacteria, and that that is definitely associated with a lot of the diseases that we study in the gut and outside the gut.

Dr. Miller: Irritable bowel is a problem for a lot of people. I know you deal with that in your practice. Is there an association between abnormalities in the microbiome and irritable bowel disease that we know about, or is that still too early to say?

Dr. Boynton: Probably the biggest association we've identified is with inflammatory bowel disease. In that case, your immune system is attacking the bacteria. The bacteria lies on the surface of the intestine. Those patients get inflammation.
Recently, there has been identification of a gene marker, that means a genetic malfunction, in patients who have irritable bowel. That's different than inflammatory bowel. Those patients have a disturbance in their microbiome coupled with the fact that they have leakiness in the gut, which means all those chemicals made by this abnormal microbiome have the ability to leak out of the gut and travel around and cause a lot of uncomfortable associations for IBS patients.

Dr. Miller: Some of the patients that I see will come in asking about leaky gut. Is that related to an abnormality in the microbiome? Can you talk about that a little bit for folks that are listening.

Dr. Boynton: Yes. We don't know a lot about leaky gut, because it's a brand new phenomenon. We know it exists. We know that in concept our gut should be what we call impenetrable, meaning that it doesn't allow chemicals that are made in the gut to escape and get to the rest of the body.
We also have realized that common things we do in our culture, for instance taking an aspirin or a non-steroidal, can lead to this leakiness. All the sudden the foods you eat may get into your bloodstream, or the chemicals made by your microbiome. In association to that, we've noticed that some of the chemicals that are made by the microbiome have the ability to create the symptoms that are part of irritable bowel.

Dr. Miller: For folks that are listening, what should they take home from this? Should they be thinking about taking probiotics? Is that something that patients should do to keep their microbiome health, or are we not yet at that stage where we can say?

Dr. Boynton: We have a lot of pieces. We think we can put them together. We think it makes sense. But, there are so many fundamental aspects that we still don't know. We don't know what the critical bacteria are in terms of each of these diseases. We don't know when they're in the pill form and you swallow them, do they even make it out of the stomach, or does the acid break it down. The companies that are producing probiotics are right in the sense that we think there is a future for probiotics, but we don't know which ones and in what format.

Dr. Miller: Still a lot of work to be done.

Dr. Boynton: A lot.

Dr. Miller: It sounds like the microbiome, if I think about it simplistically, is a nice coating in the gut to protect the lining so that barrier remains permeable only to certain things that get into our system that we need and keeps a lot of perhaps bad things, pathogens and toxins, out. Without that bacteria layer which primarily resides in the colon, we could be in trouble.

Dr. Boynton: Absolutely. In addition, the microbiome helps us absorb our calories, and probably most importantly to people who have immune related diseases, it trains our immune system. It teaches the immune system this is something that's called a pathogen, meaning a bad thing, I have to destroy it, versus this is part of my body, I need to ignore it. It may be that defects in this training process are what lead to immune related diseases. It doesn't figure out the distinction.

Dr. Miller: To wrap it up, it sounds like the microbiome is extremely important. We've known that for a long time. How we can help maintain a healthy microbiome, there remains work to be done, and future research is underway.

Dr. Boynton: That's correct.

Dr. Miller: Thank you very much.

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Dr. Miller: Heartburn, when does that become a concern, next on The Scope Radio.

Announcer: Medical news and research from University of Utah Physicians and Specialists you can use for a happier and healthier life. You're listening to The Scope.

Dr. Miller: Hi, this is Tom Miller, and I'm here with Dr. Kathleen Boynton, and she is a doctor in the Department of Medicine and she is a gastroenterologist, a specialist in gut disorders. And she is also an associate professor. She is here today to talk about heartburn.
Kathleen, when is heartburn... everybody gets heartburn, right? I mean, you have that big chili cook-off and a couple of hours later you're really resenting that and you're reaching for the sodium bicarbonate, or you're going for Tums. How often would one have heartburn and not be worried about it? Or conversely, when should somebody worry that they're having heartburn too often?

Dr. Boynton: Well the truth is nobody has ever done the study where they say this frequency equals a severe disease. But generally I tell people, if you're having it two to three times a week that's probably enough to see your physician. The other concern of course is if you come from a family with a history of esophageal cancer, perhaps any degree of heartburn is enough to see somebody.

Dr. Miller: I know a lot of patients will have heartburn maybe three times a week, and then they just have gone to the store and they've bought several different kinds of antacids. If that works, do you still think they need to see a physician?

Dr. Boynton: I think that they do, because we know that the way you feel doesn't necessarily match what's going on inside your gut. And your concern is to prevent the complications that are irreversible, that are related to heartburn.

Dr. Miller: Long-term heartburn, what are those complications?

Dr. Boynton: You can get scar tissue in the esophagus. The esophagus is made to be elastic, so if you inadvertently swallow a big piece of food it can still distend, stretch the esophagus and pass down into the stomach. If you get scar tissue it cannot pass, and we see obstructions all the time when we're on call, where somebody has a piece of meat, say, that's stuck in the esophagus and won't pass.

Dr. Miller: Then long-term heartburn can lead to scarring of the esophagus, the narrowing of the esophagus so that you can't pass food and is a dangerous situation.

Dr. Boynton: Right.

Dr. Miller: Now what about this term called Barrett's esophagus? Some patients will come in and they've read about it on the Internet or heard it on TV shows about Barrett's esophagus and its relationship to heartburn.

Dr. Boynton: Yes. Barrett's is a concerning change in the tissue and it develops as a result of exposure to acid, which causes inflammation. Inflammation means that the tissue has to regrow. And sometimes the tissue makes a mistake and it grows to look more like the tissue we see in the stomach, and then duodenum. And the problem with that is a small percentage of those people that have that Barrett's tissue will go on to develop esophageal cancer. So our question is when we see a patient with heartburn, are they somebody that may have Barrett's? How do we decide whether or not to investigate that?

Dr. Miller: Now there are age cutoffs I think; the older a person is the more likely a physician is likely to recommend diagnostics. Can you talk a little bit about that and when you decide as a gastroenterologist that a patient might in fact need a study, or a look down to see what that tissue looks like, to see if they have Barrett's esophagus?

Dr. Boynton: In medicine we have what are called guidelines, and they are in part based on associations, because we want to be efficient and not do unnecessary testing on patients. The recommendation is that in a white male over the age of 40 who has a history of heartburn that we do an endoscopy, and the endoscopy helps us. We can see the Barrett's tissue; it looks different from normal tissue.

Dr. Miller: Now the endoscopy, can we just clear that up for some people. That's a tube that goes down with a light on the end of the scope and they can actually see the tissue in the esophagus. They could even take biopsies.

Dr. Boynton: Right. And based on those biopsies we can tell someone whether or not they have Barrett's disease. If they have Barrett's then we recommend that they be monitored with endoscopy and the frequency can be in a year, or it could be every three years, depending on the profile.

Dr. Miller: Now the physician might also decide there's treatment, and are there effective treatments for heartburn that can make it better?

Dr. Boynton: Absolutely. And they are even available over the counter. The most effective are what we call the proton pump inhibitors, and there is a whole bunch of those. But the one that's over the counter is omeprazole, or Prilosec, and that's probably the most frequently used drug.

Dr. Miller: When you go you grab the omeprazole and it's probably cheaper, right?

Dr. Boynton: Yes.

Dr. Miller: And taking that daily, I think, is pretty much what's prescribed for people who have heartburn three or more times a week. And I've found most patients do very well with that; it's very effective.

Dr. Boynton: Yes.

Dr. Miller: And it stops heartburn in its tracks.

Dr. Boynton: Yes, that's correct.

Dr. Miller: Now what happens if a person is taking one of these medications and they're breaking through?

Dr. Boynton: Well in the doctor's brain, when they see those patients, what they are wondering is first of all do I have the diagnosis correct. Is this still acid? But assuming that it is still acid, we will increase their medication. If that doesn't work there is even surgery that will fix the underlying mechanical problem that causes reflux.

Dr. Miller: Now how often in your experience would a patient not respond to medication to reduce or to eliminate heartburn and need to go on to surgery? How often does that happen?

Dr. Boynton: I don't have exact numbers, but it's under 10% of patients. Sometimes patients will elect to have the surgery for lifestyle reasons. They just don't want to be on a medication long term, and that's a valid consideration.

Dr. Miller: So it sounds like the take-home points are; one, if you're having heartburn more than three times a week, you should probably see your physician and have him decide if additional diagnostic studies should be done; or if they would just go ahead and prescribe a medication, such as omeprazole that would eliminate the heartburn. And if you're having heartburn and you're taking a medication for heartburn, you really should probably see your physician about it for additional diagnostic studies.

Dr. Boynton: Right.

Dr. Miller: Thank you very much.

Dr. Boynton: You're welcome.

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