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Today's column is about rectums, mailing feces, snaky tubes and cancer; images that few of us like to linger upon.

Our portable plumbing systems, though not as symbolic as the heart or the brain, are often taken for granted. That is, until something goes wrong.

This month, the government of Ontario launches the first formal colorectal cancer screening program in Canada, ColonCancerCheck, for men and women aged 50 or older. The program aims to increase early detection and treatment, and involves a public awareness campaign, access to home screening kits and more funding for colonoscopies.

Although you probably don't know the details (in a week, an average of 400 Canadians will be diagnosed with colorectal cancer and 167 will die of it), you probably know that cancer is bad and that preventing it whenever possible is good. You may even know about the significant preventive opportunities with colon cancer (it starts as polyps that are easily removed) and that, if you catch it early, you are likely to do fine (90 per cent of people diagnosed at the first stage are cured).

My guess is that your real question is this: How embarrassing is the testing and what do I need to know to limit humiliation?

Let's begin with the screening test that is being pushed as the starting point by the Ontario government and in similar programs in England, Australia and Finland. It's called the fecal occult blood test (FOBT) and checks for blood in your stool (polyps and cancers tend to bleed). It is the easiest and least expensive test, and has significant research supporting its protective benefit (trials show testing every two years yields a 16-per-cent drop in colorectal cancer over a decade). You can get a lab requisition for the test or a kit from your family doctor or other health-care provider.

The basic premise of the test is straightforward: In the privacy of your own home, collect a small sample of your stool on three different days.

Sounds easy enough. But now comes the part doctors aren't always clear about: how to get those samples. You can chase your stool around the toilet with a popsicle stick, but there are more creative options devised by others who have travelled this road before you.

The first is the homemade version of a "stool hat." This usually involves stretching plastic wrap across the toilet under the seat to catch your stool. My clinical advice is to let it sag a bit in the centre and to keep constant pressure on the seat so the wrap does not lose its purchase.

Another method is what I call the "fecal float," in which a significant amount of toilet paper or a large disposable plate is deployed into the toilet bowl. Aim is critical here.

There is the "racing stripe" approach where your used toilet paper is mined for fresh stool (being careful to not include the TP in the sample).

Finally, some of my patients with stronger quadriceps employ the no-toilet-just-news-paper-or-paper-plate-on-the-

ground approach.

Once you have collected the stool sample, put a very thin smear on the FOBT card. Typically, labs want three different samples from three different days taken within 10 days.

Okay - that was the worst part.

After you mail in or drop off the FOBT card, the chances of blood being found in your stool are about 5 to 10 per cent. Most positive cases of blood in the stool are the result of benign reasons (you ate a steak, have a hemorrhoid or a nosebleed, which can drain down the esophagus to the colon) but many require further testing to make sure.

The next step up in testing is a colonoscopy. While more accurate, this screening test is also more invasive. It is usually done following a positive FOBT that can't be explained, or for people at high risk. If your mother, father, sibling or child has had colon cancer, especially at an age younger than 65, then you are at higher risk. There are other groups, such as people with inflammatory bowel disease (Crohn's, ulcerative colitis), who are also at higher risk.

A colonoscopy has two parts. People typically underestimate the impact of the first part and overestimate the second part. The first involves the medical version of Liquid-Plumr; a gallon of solution that you guzzle to clean out your bowels so the person doing your colonoscopy can get a more accurate picture. This means you require an all-access platinum pass to the nearest bathroom for the day before the exam. You may want to upgrade your bathroom reading collection prior to taking the bowel cleanser.

There are a wide variety of experiences with the "cleansing," ranging from stomach cramps and nausea to a beatific sense of purification. There's more of the former than the latter, I would say.

The second part of the test is the scope itself. One of the more common questions that patients ask when I introduce the concept of a flexible tube with a camera and lights entering their back end is: "How big?" Answer: It's about the size of your index finger.

The camera transmits images of your colon onto a video screen; the clinician, usually a gastroenterologist, can remove anything worrisome, such as a polyp, with microtools for further examination.

Most likely you will be lying on your side during the procedure, maybe even watching the screen (giving new meaning to reality TV) with your colonoscopist. An IV is inserted into the back of your hand and typically you are given the option of a medication to sedate and relax you. Not everybody wants to be sedated, but I would recommend this as the bowel is not used to things going the other way. As well, air is often used to inflate your bowel to get a better look and this can be uncomfortable.

An FOBT test or colonoscopy is probably not going to be the highlight of your week and can be embarrassing. There's no getting around it, except maybe with humour, and knowing that, whatever you're dragging in, we've seen worse.

Cancer is found in about two of every 1,000 colonoscopies following a positive FOBT in asymptomatic people. Reflecting upon this, if two out of 1,000 are found to have cancer, that's 1,000 slightly embarrassed people, 998 reassured people, and two people very glad they caught it early.

Put colorectal cancer screening on your to-do list. You will be rewarded with reassurance and, like many of the things we tend to procrastinate about, you will find it wasn't nearly as hard as you thought it was going to be. It's far more difficult to reassure people who didn't do the test and now have more invasive colon cancer.

Get your butt in there.

Dr. Michael Evans is an associate professor and physician at the University of Toronto, where he is leading both the Health Media Lab at the Li Ka Shing Knowledge Institute of St. Michael's Hospital and Patient Self-Management at the Centre for Effective Practice in Family & Community Medicine.

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Tips for your FOBT test

If you're using the toilet to collect a sample, urinate (if you need to) and flush first to ensure a clean sample.

The test checks for blood in your stool, so you need to put off the test if you are experiencing bleeding (gums, nosebleeds, hemorrhoids).

Newer FOBT testing kits are less sensitive to dietary changes, but in the three days prior to doing the test, the advice can be obvious - don't eat bloody meat - and less obvious - avoid excessive raw fruit and vegetables (cauliflower, apples, horseradish, turnips) and vitamin C supplements. Cooked vegetables are fine.

The use of non-steroidal anti-inflammatories (NSAIDs) such as ibuprofen and ASA should be discussed with your doctor or pharmacist as these can make you more vulnerable to bleeding. If you take ASA daily for heart-disease prevention, many will say it is okay to continue this, but try to stop other NSAIDs prior to the test.

You can also refer to:

coloncancercheck.ca, the website for the new Ontario program.

labtestsonline.org, to understand any common lab tests.

cancer.ca, the Canadian Cancer Society's website, and the U.S. National Cancer Institute's cancer.gov.

Colorectal Cancer: A Thorough and Compassionate Resource for Patients and Their Families by Bernard Levin from the American Cancer Society.

Dr. Michael Evans

mevans@globeandmail.com