Kevin, M.D. - Medical Weblog

Summed up in one line

Via Blogborygmi, our surgeon friend from A Cut to Cure . . . gives us a quote that summarizes many of the challenges and frustrations facing physicians today:

An older physician brought this up the other day during a discussion about liability premiums and declining reimbursement. It is a good, simple expression about the frustration many physicians feel:

"Why am I worth so little when I do my job right, and worth so much when I make a mistake?"

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Full-body scams indeed

As was commented on by RangelMD and Medpundit, I only have to re-iterate it here. A study was released detailing the harms of full-body scans:

. . . a 45-year-old who has annual full-body scans for 30 years would accumulate an estimated lifetime cancer mortality risk of 1.9 percent, or almost one in 50.

"The radiation dose from a full-body CT scan is comparable to the doses received by some of the atomic-bomb survivors from Hiroshima and Nagasaki, where there is clear evidence of increased cancer risk." The researchers considered the exposure only of low-dose A-bomb survivors in assessing the risk.

Considering that many who obtain these scans are healthy adults, it seems unwise to expose them to this unnecessary risk.

To further emphasize that these scans are not recommended by any expert groups, here are the current guidelines from UptoDate:

* There are no data that total body imaging improves outcomes.
* Potential harms of total body body imaging include: false-positive results leading to unnecessary tests and procedures as well as psychological distress, true-positive results leading to overdiagnosis of disease and futile therapies, and individual and societal costs.
* In the absence of additional data from well-performed controlled trials of total body imaging, we recommend that low-risk asymptomatic individuals not undergo such screening. As people self-refer for total body imaging, clinicians will be confronted with suspicious results on imaging without good data on their implications or the appropriate additional steps for diagnosis and management.

Need I say more?

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Follow the leader? Not so fast

In a blatant attempt to capitalize on the MIRACL study sponsored by Pfizer, it seems that Merck's attempts have blown up in their faces. As a reminder, the MIRACL study reported a 16% lower rate of death and nonfatal major cardiac events 4 months after acute coronary syndrome (ACS) in patients receiving 80 mg/d of atorvastatin compared with placebo. This is contrast to the current Zocor study, named the A to Z study:

Conclusions The trial did not achieve the prespecified end point. However, among patients with ACS, the early initiation of an aggressive simvastatin regimen resulted in a favorable trend toward reduction of major cardiovascular events . . .

[MIRACL's conclusions are] a finding that is in contrast to the A to Z trial, in which no effect of aggressive statin therapy was observed for the end point of readmission for ACS.

Worse, episodes of myopathy in the intensive Zocor dose were significantly more than the lower dose. I do not believe that myopathy was seen during higher doses of Lipitor in the MIRACL study.

What this suggests is that statins are not interchangeable. Merck obviously wanted this to be the "me too" study, emulating what the MIRACL study did for Lipitor. This is clearly not the case, and probably will lead to some hesitation in future high-dose Zocor use.

As an aside to patients - this does not mean that Zocor is an unsafe medication. This study only applies to 80mg doses, which is an extremely high, uncommon dose for this drug.

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A third of Americans . . .

. . . take vitamin supplements every day, and I receive continual questions during my office visits about whether they work or not. This nice article summarizes the bottom line: save for a few, most vitamins do not have the appropriate evidence to back their general use.

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Risk factors for heart disease

In a study that will be published in The Lancet shortly, comes the most definitive look at risk factors causing heart disease. Some key observations:

* 90% of the risk factors can be prevented
* risk factors are similar across different regions and race

So, what are the risk factors? Here they are, in order of importance:

1) poor HDL/LDL ratio
2) smoking
3) diabetes
4) stress
5) poor vegetable and/or fruit intake
6) lack of exercise

The importance of stress comes as a surprise. I believe this is one of the first major studies that acknowledges its importance. More to come when I can read the actual abstract when it is published in a few weeks.

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Why EBM won't fly in the United States

There is an interesting discussion going on at Blogborygmi. Nick applied the evidence-based Ottawa ankle rules in a situation, only to be overruled by his attending - "in our country, I can't afford not to get an X-ray." Discussion ensued in the comments, with arguments discussing whether EBM is merely a cost-containment strategy versus good medicine.

I would agree with the attending in this case. Until physicians are sued for doing too much testing, I will always err on the side of extra testing. Cover-your-ass indeed. The reality is this - they always get you for the zebra you miss. We are in a nation where physicians are practicing two forms of medicine - "correct", evidence-based medicine and United States-style, defensive medicine.

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Old dog, new tricks?

So I was having a discussion with a friendly drug rep about McNeil's drug, Flexeril. Now, this is not a new medication, but the 5mg formulation is. The big selling point is similar amount of muscle relaxation with less sedation. What's left out is that the regular 10mg of Flexeril is a generic medication, but 5mg is brand-name only, meaning it's third tier on most health plans. The difference in co-pay's can be as high as $35. A slick way to continue reaping profits from an old, generic, medication.

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Lest we think that . . .

. . . frivolous lawsuits are an American-only phenomenon, fear not - it happens in Korea as well.

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Talk about a free-market

Singapore is offering "medical tourism", slashing rates of medical procedures to lure overseas patients. I guess that's one way to increase revenue.

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Back to basics

As we continue to get blitzed with happy-meal style medications like Azithromycin Z-paks and Tri-paks, Biaxin XL-paks, and Levaquin Leva-paks, consider the most recent review from NEJM on bacterial sinusitis. Some excerpts:

In an analysis of a large pharmaceutical database, 29,102 patients were identified with a billing diagnosis of acute sinusitis and a related prescription for an antimicrobial agent. Clinical success was defined as the absence of an additional prescription for an antimicrobial agent within 28 days after the initial prescription. The success rate was 90.1 percent for the patients who received older antimicrobial agents (e.g., amoxicillin, trimethoprim-–sulfamethoxazole, and erythromycin) and 90.8 percent for the patients who received newer drugs (e.g., clarithromycin, azithromycin, and amoxicillin–-clavulanate). Serious complications (such as brain abscess and meningitis) occurred in one patient in each group. The average pharmaceutical charge was $18 for patients receiving older antimicrobial agents and $81 for those receiving newer antimicrobial agents.

In other words, this retrospective study suggests equivalent efficacy between "older" (i.e. amox, bactrim, erythro) and "newer" (i.e. biaxin, azithromycin, augmentin) antibiotics with the older antibiotics costing 1/4th as much. Bottom line from the article:

For patients who have "severe or persistent moderate" symptoms (these terms are not defined in the guidelines but are generally considered sufficient to result potentially in lost workdays) and in whom there are specific findings of bacterial sinusitis, amoxicillin, doxycycline, or trimethoprim–sulfamethoxazole should be prescribed as reasonable first-line therapy.

Just thought I'd give generic antibiotics a plug, since they don't have the marketing budget the drug companies do.

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Not what Merck wants to hear . . .

I'm sure that they're in damage control mode after reading about how Vioxx increases heart attack risk.

Patients taking Merck & Co. Inc.'s Vioxx arthritis drug had a 50 percent greater chance of heart attacks and sudden cardiac death than individuals using Pfizer Inc.'s rival Celebrex medicine, according to a large study financed by the U.S. Food and Drug Administration. . .

The study also found patients taking the highest recommended daily dosage of Vioxx had three times the risk of heart attack and sudden cardiac death as those not taking standard painkillers.

The study will be published in the Lancet in a few weeks. I'm not able to find an abstract of the study (if someone can email me a link, it would be much appreciated). From what I gather, it's an observational study - the weakest kind. I'll have to read the actual study, but I'll probably think twice about giving Vioxx to those who have, or are at high risk, for heart disease.

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The black box of health care costs

Trent has written a dissenting opinion on the piece by Mr. Baker yesterday in the Boston Globe. He writes:

Consumers only want and seek the information if the benefits of such information exceed the costs of finding it. Part of the reason things stand as they do is that patients do not save from finding this pricing information. This is the fundamental problem with third-party payers, whether they be HMOs in a employer-based insurance structure or governments in a national health care system. Why would anyone ever have the incentive to seek price information, and more importantly, to act on that information, if the benefits acrue to a third party?

With the inevitable and growing trend towards deductible insurance, patients will have no choice but to shop around for the best price on tests. With the responsibility of costs shifting to the patient, you can bet that's pretty good incentive to seek price information. The days of comprehensive third-party payer coverage are over. Also, informing patients on the cost can certainly cut down on unnecessary testing that patients frequently demand; especially if it comes out of their own pocket.

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Today's op-ed in the Boston Globe . . .

. . . gives Charlie Baker's opinion on disclosing health care costs to the public. He is the CEO of Harvard Pilgrim Health Care, an HMO in Massachusetts. I completely agree with his comments.

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Another article . . .

. . . on physician blogs.

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ER doc turned malpractice prosecutor

Fascinating interview with Bruce Fagel, a former ER physician who is now a malpractice attorney. He touches on which doctors he sues, the costs of litigation, and opinions on tort reform.

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The growth and challenges of e-consultations

I am a pretty big supporter of e-health - that is educating and empowering patients to take control of their health using the internet. With this new resource, comes many dangers - especially in the form of incorrect medical information and misinterpretation of information. Two articles from the BMJ discusses the effectiveness and challenges of e-mail consultations.

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Websites promoting anorexia

There's a disturbing new trend - pro-anorexia websites. Sad, in more ways than one.

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BKA = "Baloney amputation"

Maybe I shouldn't laugh, since we also outsource our transcription to India. But, I couldn't help but to chuckle at some of the transcription errors from outsourcing.

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Open access

A good case for same-day appointments. Our practice currently uses this model (allowing several same-day urgent care visits per physician) with good success. Patients are happy with the improved access, and these slots invariably fill.

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Check out . . .

. . . Carotids.com - "an irreverent look at the latest medical news. We as health professionals enjoy learning, discussing, and laughing at the latest news and research. Get your real research from your journals. Come here to laugh and chat about our wonderful professions."

Some good stuff on this website and more than a few laughs. I've added it to my Blogroll.

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More coronary artery disease screening and EBCT

Galen has bluntly chimed in on the study comparing exercise stress testing and calcium scores from electron beam computed tomography (EBCT) that the lay press has been reporting.

As we brace ourselves for patients demanding EBCT, let's consider the data and recommendations. Again, UptoDate comes in handy:

Coronary calcification detected by EBCT is found in individuals who have significant angiographic CHD, with a sensitivity ranging from 90 to 100 percent, a specificity of 45 to 76 percent, a positive predictive accuracy of 55 to 84 percent, and a negative predictive accuracy of 84 to 100 percent . . .

In 2000, the American College of Cardiology/American Heart Association (ACC/AHA) published an Expert Consensus Document that made recommendations concerning the use of EBCT that have been controversial [61]. The panel raised questions about the reported low specificity of EBCT calcium scores and concluded that EBCT cannot be recommended for the diagnosis of obstructive CHD because of its low specificity, which can result in additional expensive and unnecessary testing to rule out a diagnosis of CHD. However, subsequent data have suggested that EBCT calcium scoring is cost effective when applied to symptomatic patients at low to intermediate pretest likelihood for obstructive CHD [62] and that, when analysis for verification bias is performed, specificity is higher [34].

At present, there are insufficient data to recommend the use of EBCT calcium scoring as a single diagnostic modality for screening of low risk, asymptomatic subjects; however, there are data to support its use in the "intermediate" risk asymptomatic patient in whom the contribution of multiple sub-threshold risk factors is difficult to determine using conventional risk assessment strategies.

There you have it. EBCT has no role in asymptomatic, low risk patients. It has a role in intermediate risk patients where conventional stress testing cannot be done. Helpful data to answer the onset of patient inquiries tomorrow.

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Sound familiar?

Poor reimbursement rates for dealing with the indigent population, leading to a shortage of those who represent them. Another story on our broken health care system? No - apparently, the same thing is happening to lawyers.

Lawyers, welcome to our world.

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Exercise stress testing

The lay press is all over this study, blaring out this headline: Stress Test May Miss Early Heart Disease. Here were the participants in the study:

Most were men over 45 or women over 55, smokers, people with high cholesterol or high blood pressure, diabetes or a close relative with early heart disease, they reported in this week's issue of the Journal of the American College of Cardiology.

The 1,195 patients in the study had no evidence of heart disease, had stress tests and then a procedure called coronary calcium scanning within six months.

One should take into consideration that it is already known that the sensitivity of exercise stress testing in asymptommatic patients is relatively low. From UptoDate:

A meta-analysis of 147 published reports including over 24,000 patients compared the test performance of exercise ECG testing (compared to angiography) in patients with an intermediate pretest risk (25 to 75 percent) of CHD [5,6]. The overall sensitivity and specificity of exercise ECG testing were 68 and 77 percent, respectively; comparable values (67 and 72 percent) were obtained when patients with a prior myocardial infarction were excluded [5].

Exercise stress testing is not meant for those without symptoms, as evidenced by the recent USPSTF guidelines. Of course it is going to suffer in comparison to coronary calcium scores, and this study isn't really reporting anything new.

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A website . . .

. . . allowing those to comparison shop for prescription medication is proving to be quite popular in New York state.

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Morning news rounds

I have an extra half-hour this morning before I see patients, so here are some interesting stories to start your day.

Despite tort reform, some physicians are leaving high-risk practice.

An article on people who steal physician identities.

I do some work at the VA, so I see first-hand many of the primary care physician shortages (6+ month wait in some cases). With a dependence on IMGs, the situation is only worsening.

Discussion of the pros and cons of a Kerry-Edwards ticket and what it means to physicians.

Debate on how effective the new anti-viral tissues would be.

A study showing that veterans with diabetes get better care under the Department of Veterans Affairs system than some patients using managed care. It is inferred that a nationally-funded health-care system can meet or exceed current managed care standards.

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Colonoscopies overdone?

Today's Annals of Internal Medicine reports a study suggesting that colonoscopies may be overdone. This story was picked up by the lay press.

With regards to hyperplastic polyps, the guidelines are unclear. Here is what UptoDate says:

At the present time, there is no clear consensus regarding what recommendations should be given to asymptomatic patients at average risk for CRC who are found to have a distal hyperplastic polyp on a screening sigmoidoscopy. Thus, decisions should be individualized after informing the patient of the uncertainty versus the risks and benefits of a colonoscopy.

The article provides more clarity and comes up with this recommendation:

Clinical practice guidelines for adenoma surveillance typically recommend colonoscopy at 3 years after finding a large adenoma and at 3 to 5 years after detection of a small adenoma; surveillance is not recommended for a hyperplastic polyp.

With these guidelines in mind, here are the results of the survey:

Among gastroenterologists (317 of 349) and surgeons (125 of 316) who perform screening colonoscopy, 24% (95% CI, 19.3% to 28.7%) of gastroenterologists and 54% (CI, 44.9% to 62.5%) of surgeons recommend surveillance for a hyperplastic polyp. For a small adenoma, most physicians recommended surveillance colonoscopy and more than 50% recommended examinations every 3 years or more often.

These findings suggest that colonoscopies are overused, contributing to the worsening wait-times for this procedure as well as increasing health-care costs.

However, do guidelines really matter in real-world medicine? They don't even stand up in court. Remember, physicians are sued for doing too little and missing the "one that got away", and never for doing too much. Until defensive medicine is reigned in and punished, it's unlikely that this colonoscopy trend would change.

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A story . . .

. . . from the BMJ where it was assumed that test results would be conveyed expediently to a patient. Unfortunately, it wasn't - leading to days of anxiety.

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What a fitting tribute . . .

. . . to life on the general medicine service (via Medrants).

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Doctors and white coats

Interesting study - most patients seem to want their physicians to wear white coats:

In contrast to doctors, who view white coats as an infection risk, most patients, and especially those older than 70 years, feel that doctors should wear them for easy identification. Further studies are needed to assess whether this affects patients’ perceived quality of care and whether patient education will alter this view.

I find wearing a white coat a matter of convenience - it provides easy access to my PDA, stethoscope, pens, and prescription pad. Without the white coat, I'd be leaving things all over the place.

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Smoke free or die

In my home state, where motercyclists can ride without helmets, New Hampshire is becoming one of the last states to ban smoking in restaurants. Tough to be a public health officer here when you do not have the support of the state. As one such officer puts it: "New Hampshire is becoming the ashtray of New England".

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The future of primary care

The New England Journal published a sounding board piece on the future of primary care in the United States. The authors suggest that one paradoxical reason is the increased exposure to primary care in residency training:

But an additional possibility, albeit an apparently paradoxical one, is that the decline is due in part to the successful efforts by medical schools to increase students' exposure to primary care practice. How can this be? And if it is true, what might be done about it?

To understand this dynamic, it is important to recognize what students observe about primary care practice during medical school. In most schools, students spend some time during their first two years in the offices of community-based primary care practitioners, where they observe the reality of this type of practice and gain insight into the challenge of caring for patients with a wide range of conditions, including serious chronic diseases. . .

However, during the actual medicine clerkship, the majority of training is spent on an inpatient venue - essentially what students are seeing is the failure of outpatient medicine:

During these clerkships, they once again observe patients with chronic diseases, many of whom have been hospitalized because of inadequate or inappropriate treatment of their underlying diseases. And although students may see how the episodic conditions that precipitate hospitalization are managed, they cannot help but notice how little attention the attending physicians and residents devote to considering how hospitalization might have been avoided through better outpatient management.

It is this constant exposure to "outpatient failures" that causes hesitation to a career in primary care:

As a consequence, we believe that the clerkships discourage many students from pursuing residency training in a primary care specialty, because they are concerned that they will not be adequately prepared to meet the responsibilities of such a practice.

This is certainly a valid point. It has taken me the greater part of two years to comfortably make the transition from residency to primary care. To this day, I continue to feel more comfortable taking care of an acute MI than I do a rash.

Solutions? The authors suggest redesigning primary care residency programs to further focus on the skills needed for ambulatory care - and not treat it like an afterthought. The alternative is a grim scenario:

Unless these changes are made — and made soon — the practice of primary care medicine seems destined to become the province of nurses and other nonphysician health care professionals.

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New pain guidelines

While I was on vacation, the DEA released guidelines "designed to help doctors prescribe narcotics like Oxycontin and morphine without fear of arrest".

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IM vs oral steroid therapy for asthma

A recent study suggests that a single IM dose of steroid is equivalent as an 8-day tapering course of oral steroid in the setting of relapse rates from acute asthma attacks:

Objective: To compare the efficacy of long-acting IM methylprednisolone to tapering oral methylprednisolone in adult asthmatic patients discharged from the emergency department (ED).

Methods: Randomized, double-blind, placebo-controlled trial of a single IM dose of 160 mg depot methylprednisolone vs 8-day tapering of a total dose of 160 mg oral methylprednisolone in adult asthmatic patients (age range, 18 to 45 years) who were discharged from the ED following standardized treatment for an acute exacerbation. The primary end point was relapse, which was defined as the need to seek unscheduled care at a doctor’s office, clinic, or ED for symptoms of persistent or worsening asthma within 10 days of ED discharge.

Results: Of 190 patients enrolled into the study, 180 completed the study and the follow-up at 10 days (96%). The relapse rate was nearly identical for the two treatment groups (IM administration, 14.1% [13 of 92 patients]; oral administration, 13.6% [12 of 88 patients]; difference, 0.5% [95% confidence interval, – 9.6 to 10.6%]).

Conclusions: Single-dose IM methylprednisolone administered to adult asthmatic patients at ED discharge appears to be a viable therapeutic alternative to a course of oral methylprednisolone. Clinicians may choose to base the route of administration of corticosteroids on concerns about nonadherence to therapy or on the ability of a patient to afford a prescription for outpatient medication.

Certainly something to consider in those who may be non-compliant with a tapering course (which entails a significant amount of pills). It will be on the back of my mind when I moonlight in urgent care this Friday.

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I'm back . . .

. . . from a wonderful vacation and ready to work. Forums will be open later today, and I'll slowly answer my email.

I went to lovely St. Martin, the culinary capital of the Caribbean. The small fishing village of Grand Case hosts an unbelievable array of fantastic dining - and it surely did not disappoint. Highly recommended to any gourmet gurus.

Unfortunately with all the sun, the minocycline I was on didn't agree with my skin and I had a pretty bad photosensitive reaction. I'm now back in New Hampshire, where the sun isn't a problem.

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Some interesting reading . . .

. . . while I'm gone:

The dangers of medical advisory board scams.

A poignant story, entitled "It's not just what we say."

Another story on the rewards of medicine.

A new addition to the Scutmonkey Comics.

Overlawyered links to some comments on my "Screen me or I'll sue" story.

Medrants discusses the levels of thinking in regards to the recent adverse effects of spironolactone and CHF.

See you all in a week.

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Out of the country . . .

. . . and without internet access. Apologies in advance if I don't respond to emails. Regular blogging will continue when I return and my forums will reopen on August 14th.

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Hyperkalemia from the RALES study

The RALES study, published in 1999, concluded that spironolactone reduce mortality in those with severe heart failure (i.e. Class IV failure). Today's NEJM comes out with a study showing that due to the RALES study, rates of hyperkalemia and mortality from this complication increased. Taking this into account, there were no significant decreases in death from all causes.

The reason for this is that most patients with CHF are concurrently on ace-inhibitors, and the combination of this medication with spironolactone can lead to hyperkalemia.

This trial is a good example of applying clinical trial medicine to the real world. An excerpt from the editorial:

What lessons can we learn from the post-RALES experience reported by Juurlink et al. and others? First, every effort should be made to define the inclusion criteria for clinical trials as broadly, and the exclusion criteria as narrowly, as possible, so that the findings are relevant to the greatest proportion of patients in clinical practice. Second, it behooves the sponsors and leaders of trials to educate physicians about the careful use of the study treatment. For their part, physicians who prescribe the treatment must fully familiarize themselves with the way in which it was used in the trial and with the contraindications, cautions, adverse effects, and drug interactions. Guidelines may need to do more than recommend which treatments should be used; practical guidance on how to use them is also needed. Finally, we need to make more linked data sets, such as those in Ontario, accessible to interested research groups and formal post-marketing surveillance programs.

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Waits for mammograms

A few weeks ago, one of my colleague's sister from Ireland came over for a visit. The wait for a screening mammogram there was 6 months. She decided to pay out of pocket to have one here. It was booked for her the next day. However, in some parts of the country, the wait times are growing.

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A study showing . . .

. . . that triptans do not increase the rate of heart attack and stroke. Reassuring for migraine sufferers.

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Any theories . . .

. . . as to what happened to this unfortunate boy? A previously-healthy 13-year old was hiking and saw a bear in the woods. After running away, he went into respiratory distress and collapsed. Would it be possible for the catecholamine release to trigger some sort of arrhythmia?

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Fed up with . . .

. . . the inaction of tort reform, two towns in Illinois are taking matters into their own hands.

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Other uses of Viagra

Other than erectile dysfunction, Viagra has been studied in the treatment of pulmonary hypertension. Today's Annals of Internal Medicine presents a small study showing Viagra increased exercise capacity both in normal and high altitudes, suggesting a possible use in managing acute mountain sickness or other conditions caused by low oxygen levels at the alveoli.

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The myth of antioxidant supplements

As I have been continually telling my patients, antioxidant supplements do not have the appropriate evidence to support their use. Today, the American Heart Association agreed.

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Winning Gmail entry #4

It's been awhile since I've received any submissions for my remaining Gmail invites. I still have 3 more left. Send me any entertaining, medically-related story or article, and I'll give a Gmail invite to what I find interesting. I give preference to entries that are well-written.

This morning, I received this story from someone who works with the developmentally disabled. An eye-opener to say the least.

I work for a nonprofit that funds services for developmentally disabled folks. We constantly have to battle medical professionals to provide decent medical care for our consumers. Physicians need to be educated in developmental disabilities, to realize that people with Autism or mental retardation, for example, can experience quality of life just like their non-disabled peers. I have had clients diagnosed with dementia who were in their 40's and had nothing wrong other than mild mental retardation. We have a physician on staff who spends a great deal of his time ensuring that our clients who go into the hospital are not automatically issued a DNR (illegal to do so, but it happens with our clients - I guess they think it's not worth it to resuscitate someone who is retarded and nonverbal)? We often have to work very hard to advocate for our clients, just so they can obtain medical and dental care. Some doctors refuse to order routine or needed tests. For example, we have a client who is currently in a skilled nursing facility. He had a G-tube that kept coming out, and the nurses at the SNF could not reinsert it so they sent him to the hospital. His physician at the hospital sent him back to the SNF without an evaluation from a speech therapist and without a swallow test to see if was in danger of aspirating. The physician said that he didn't need a G-tube, and to feed him by mouth from now on. I'd like the medical community to be aware that people with developmental disabilities are PEOPLE, and have many of same capabilities as the non-disabled, and can and do live happy, fulfilling, quality lives. They deserve to have the same medial care and attention as anyone!

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The strain of screening

As screening modalities emerge and grow more expensive (i.e. take the recent studies on screening MRIs for breast cancer in high-risk patients), can our health system handle the strain?

Consider the colorectal cancer screening. We all know that a colonoscopy is one option for colon cancer screening. However, there is no direct data that screening colonoscopies reduce mortality:

The USPSTF found good evidence that periodic fecal occult blood testing (FOBT) reduces mortality from colorectal cancer and fair evidence that sigmoidoscopy alone or in combination with FOBT reduces mortality. The USPSTF did not find direct evidence that screening colonoscopy is effective in reducing colorectal cancer mortality . . .

With the increased awareness, there is increased demand - so much so, it is taxing the system - resulting in Canada-like waits for tests.

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