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I've had four colonoscopy exams since I turned 50. It's been worth the effort. So far, I have had 13 colon polyps removed - all "precancerous." That's 13 potential colon cancers prevented. In a few weeks, I'll be undergoing my fifth colonoscopy. Just like my patients, I am more concerned about the preparation or "prep," than I am about the exam itself. Recently, we made a big change to our colonoscopy preps which I would like to explain.

What! You have to be kidding! Do you mean to tell me that to prepare for next week's colonoscopy exam, not only do I have to starve myself for a day and then take a powerful laxative solution - BUT you're also making me get up at 3 AM to finish my prep? What is this all about? I didn't have to do this five years ago with my last exam. Is this really necessary? Dr. Fusco, please call me back.

This was the voicemail I recently received from one of my patients regarding his preparation for an upcoming colonoscopy exam. As you can see, he was a bit upset about our new preparation (prep) instructions. We have made some changes and it's all about accuracy. I thought perhaps I should explain.

Before we proceed, let's briefly review a few facts about colon cancer:

1. Colon cancer is NOT rare. In fact, it is a common, deadly and silent disease. We find new cases of colon cancer in our practice every week. About 1 in 17 Americans are eventually affected. Few people know that colon cancer is the number one cancer killer of Americans - if you exclude smokers. Only lung cancer is more deadly. Unfortunately, there are no early warning symptoms. By the time they have symptoms (rectal bleeding, change in bowel habits, abdominal pain, weight loss, anemia, etc), patients are often dealing with an advanced cancer resistant to all the tools of modern medicine. We see a lot of tragic cases. This is the bad news.

2. Now the good news. Colon cancer is unique in that it can be prevented. This is because almost every colon cancer begins many years before as a small benign (noncancerous) growth called a polyp. It may take ten years for that small polyp to grow larger and turn malignant (cancer). Unfortunately, there are no symptoms of a polyp. But if an individual makes the effort to find and remove that polyp before it turns malignant, the cancer they were destined to develop is prevented. This is unlike most other common cancers (breast, prostate, lung, kidney, brain, pancreas. etc.) which cannot be prevented. These cancers can't be diagnosed until after cancer cells actually develop - often too late for a cure. Colon cancer is different. We can find it before you get it.



3. For over 30 years, we have had the technology to prevent colon cancer by finding and removing any polyps that are present. This technology - know as screening colonoscopy - allows us to find your future colon cancer even before you get it. It's a miracle that most people don't understand. I think that is because this process is often referred to as "Colon Cancer Screening." This terminology is really not accurate. A more appropriate terminology would be "Colon Cancer Prevention through Colon Polyp Screening." Sadly, many individuals still are not screened. Researchers with the U.S. Centers for Disease Control and Prevention reported in January 2012 that over 40% of Americans still do not comply with screening recommendations.

By finding unsuspected polyps and removing them by a procedure called polypectomy, screening colonoscopy has been shown to greatly reduce your personal risk of colon cancer. By the age of 50, every adult should undergo periodic screening. Colonoscopy is an important test and it is crucial that it be performed accurately.

The accuracy of colonoscopy exam depends on three factors:

1. First, you need an experienced doctor who has performed many exams and knows best how to find and remove colon polyps. All the physicians in our group have performed thousands of "scopes." For example, in my 35-year career, I have performed over 46,000 procedures most of which were colonoscopies. Experience counts.

2. In terms of accuracy, a less important factor is the equipment used and the environment in which the procedure is performed. Factors such as the type of instruments used, the type of anesthetic given, the quality of the nursing staff, and cleanliness of the facility are all important for patient safety and comfort, but do not greatly affect accuracy.

3. Probably the most important factor affecting accuracy is what you do at home to prepare for the examination. This is referred to as your "prep." The quality of the laxative preparation is the one factor which you have the most control over. You can have the best and most experienced doctor in the world using the latest equipment in a wonderful modern facility, but if your colon is not well cleaned out, the accuracy of the test is greatly diminished.

Why we changed our prep
For many years, we have used a large volume liquid laxative prep such as GoLytely or NuLytely. Patients were instructed to drink all 4 liters the night before the examination. This usually worked well, but in some cases the right side of the colon and cecum (see illustration) were not well cleaned out and therefore difficult to examine. Clinical research studies then demonstrated that the cecum and right colon were areas where polyps were most likely to be missed.

Why is this? As you can see in this illustration, the small intestine drains its contents directly into the cecum and right colon. This process goes on 24 hours a day whether you eat or not. Our previous prep regimen did a good job of cleaning out the colon the night before the exam. But while patients slept overnight, the digestive juices, liver bile, and pancreatic fluids drained out of the small intestine and into the cecum often coating the lining with a yellow viscous liver bile. Occasionally, these secretions would impair the doctor's view of the cecum.

Fixing the problem
Once this problem was identified, scientific studies were performed to find a solution. These studies determined that if patients took half of the prep solution the night before their exam and the other half about five hours before their exam, the preparation of the colon was much improved. It was like the first half cleaned out the colon and the second half polished it even more. Patients who used the new SPLIT PREP had much better preps and the doctors could then perform a more accurate exam.

What this means to our patients
So improved accuracy is the reason why we converted to the split prep procedure. We know that this is inconvenient, but it makes the test more accurate, and accuracy is key. So now we ask our patients to take about half of the solution the evening before their exam, and the second half about five hours before the exam, over a one hour period. Then they must be totally fasting for the 4 hours before the exam. No food, fluids, gum, candy, etc.

This means that if you want an early morning appointment, you have to awaken in the middle of the night to finish your prep. If your test is planned for 8 am, you have to consume the second part of the prep between 3 am and 4 am. Not very convenient and not much fun, but very important.

Let's do it right
This is an important test. You want it done right and don't want to do it often. You certainly don't want to repeat it because the prep wasn't very good. Just bite the bullet and do what you have to do. If that means missing a few meals and taking a laxative in the middle of the night, then just do it. The quality of your prep is the one part of the exam that you have control over. Take advantage of that and give your doctor the best view possible. You never know. You might win a gold star for a job well done.