Colonoscopy and other screening options for colon cancer

It’s exceedingly uncommon for a healthy middle-aged man to walk into his doctor’s office and demand a colonoscopy. But even though he lacked a family history, Stanley Thornton, an African-American engineer who was then in his mid-40’s, wouldn’t take no for an answer.

“I was concerned that African-Americans do get colorectal cancer earlier, and I said, ‘hey, let me lead by example,’” he said recently. “We argued about it for a month or two. He felt I should wait until I was 50.”

Eventually, Mr. Thornton got the test, and was found to be clear of cancer. He describes the “prep” – the liquid that he had to drink to clean out his intestines the night before the procedure – as “not the nicest thing in the world” – and said he was apprehensive as his wife drove him to his appointment that morning, since he didn’t know what to expect. But he said the only uncomfortable part of the test, in which a doctor put a thin tube up his rectum in order to inspect his large intestine, was when the nurse inserted an intravenous needle to give him a sedative. “All I remember is talking and then being wheeled back to the room.”

Colorectal cancer is the second leading cause of cancer death in the U.S., after lung cancer. It’s one of the easiest cancers to pick up early, since it usually begins as a growth called a polyp that grows silently for many years before spreading into the body. Screening people between the ages of 50 and 75 for colorectal cancer is so effective at preventing deaths that the United States Preventive Services Task Force (USPSTF) gives it an “A” rating, higher than its ratings for breast and prostate cancer screening.

People who have a family history or medical condition that increase their risk of colorectal cancer usually need to start getting colonoscopies before age 50. One doctors’ group, the American College of Gastroenterology, recommends that black men start getting colonoscopies at age 45, because they are at higher risk of being diagnosed with colorectal cancer after it’s already spread (and is thus more difficult to treat), and dying of the disease,.

A colonoscopy is considered the “gold standard” screening test for colorectal cancer, since it’s the best at detecting pre-cancerous changes and since it’s the only test in which the doctor can remove the polyp right away. But it can be expensive (running anywhere from $500 to $3000 if you’re paying out of pocket) and has some small risks, such as perforating the colon (which occurs in fewer than 1 out of 1000 people) and bleeding, which is more of a risk if you are on a medicine that interferes with clotting. For most people, the most bothersome thing about a colonoscopy is the “prep,” or strong laxative that they must use to clean out their colon in advance of the test. Colonoscopies need to be done in a closely monitored environment, since they require that the person receive a sedative. If the first screening colonoscopy doesn’t show anything abnormal, most “average risk” people can wait 10 years before repeating the test.

Many, if not most, insurance plans cover screening colonoscopy in people 50 and older. But what if you lack insurance, have a plan that doesn’t cover it, are at high risk for a complication, or simply can’t stand the thought of the test? The USPSTF says it’s also OK to screen “average risk” people with high sensitivity fecal occult blood tests, which look for globin, a component of blood cells that’s concealed in the stool. This test is a lot less expensive (usually costing under $30 if you are paying out of pocket; many insurance plans will cover it), but it must be repeated every year to be most effective at catching colorectal cancer early. To do the high sensitivity fecal occult blood test correctly, you have to take home 2 cards and swabs on which you will smear your stool after 2 different bowel movements. Many physicians give their patients an older type of home fecal occult blood test called the guiac test, which involves 3 cards; the USPSTF says this is not as effective as the newer high sensitivity method, and no longer recommends it. You should also be aware that simply having your stool smeared on a single card (which doctors sometimes do as part of an office rectal exam) is not an adequate screening test for colorectal cancer.

The USPSTF also says it’s acceptable to do a flexible sigmoidoscopy every 5 years, in combination with high sensitivity fecal occult blood testing every 3 years, as a screening test. The flexible sigmoidoscopy is similar to a colonoscopy, except that the tube the doctor uses is shorter, so that he or she can only see the lower part of the large intestine, and might miss a cancer that’s higher up. It doesn’t require sedation and is less expensive, usually running less than $300 if you are paying the full cost.  A recent large study done in the UK showed that screening people with a flexible sigmoidoscopy one time can significantly reduce death from colorectal cancer.

Keep in mind that if your fecal occult blood test or flexible sigmoidoscopy show anything concerning for cancer, you’ll need to undergo a full colonoscopy, so that the doctor can look more thoroughly and remove any suspicious tissue for additional tests. Also, even if you’ve had a clean colonoscopy within the past 10 years, you may need to repeat the test if you notice blood or other changes in your stool – so don’t ignore such symptoms.

What about screening for colorectal cancer using the fecal DNA test, or virtual colonoscopy? At this point in time, the USPSTF says there isn’t adequate proof that the benefits of such strategies outweigh the harms, and gives them an “incomplete” rating. (The American Cancer Society and Multi-Society Task Force on Colorectal Cancer do say these are acceptable). Both are expensive. Virtual colonoscopy requires a bowel prep, and exposes patients to radiation.

In recent years, many doctors have been offering patients a slightly easier colonoscopy prep, involving either a smaller amount of liquid laxative than in the past, or laxative pills instead. Taking the prep correctly is important, since even a small amount of stool could hide an abnormality. It’s important to drink plenty of water and/or clear fluids on the day before the test, to keep yourself hydrated. (Avoid anything red or pink, though). Some people also suggest putting yellow lemonade Crystal Light powder in the liquid prep and refrigerating it for a day to make it a bit more palatable. If you have a history of kidney or heart problems, tell your doctor, since there are certain types of preps that you may need to avoid.

Stanley Thornton, who is now in his 50’s, underwent a second screening colonoscopy recently, and said the prep was “much cleaner and nicer.”

Many of my patients want to get a colonoscopy, but simply can’t afford the upfront costs. The U.S. Centers for Disease Control funds some limited programs to screen low-income people for colorectal cancer. New York City has a relatively generous colonoscopy screening program for people who lack insurance.

Stanley Thornton, who is active in the American Cancer Society, urges everyone 50 and older with financial access to a colonoscopy to get the test. “The ‘big C’ is something we don’t like to talk about in the black community, but we need to take charge of our health and get it done,” he said. “Anything short of that, we’re shortchanging ourselves.”

Erin Marcus is an internal medicine physician.
A similar version of this article originally appeared in New America Media.

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  • http://www.TheHealthCulture.com Jan Henderson

    Dr. Marcus – I enjoyed your cogent and informative article.

    In case you haven’t yet seen it, there’s an interesting commentary in the July 28 JAMA on whether colonoscopy is actually superior to sigmoidoscopy in reducing colorectal cancer mortality (Colonoscopy vs Sigmoidoscopy Screening – Getting It Right). The authors site a case-control study and two subsequent observational studies that found the observed reduction in cancer mortality with colonoscopy was limited to left-sided cancers. Possible explanations include inadequate bowel preparation of the proximal colon, flat lesions, and difficulty reaching the cecum. The article includes a table with results from six studies and states: “The accumulating evidence has not established the long-held belief that colonoscopy carries greater benefits than sigmoidoscopy.”

    The conclusion: “If further evidence supports a lack of efficacy of colonoscopy for reducing incidence and mortality for right-sided colorectal cancer, the medical community should be prepared to consider returning to sigmoidoscopy for endoscopic screening of average-risk individuals.”

    I’m not a physician myself, but I’m interested in the process by which the medical profession arrives at a conclusion such as this and then implements it. In particular, I’m interested in how important and difficult it must be to educate the public about such decisions. I can easily imagine that a return to sigmoidoscopy would be portrayed by some as a strictly financial decision and that individuals would continue to lobby their doctors for colonoscopies.

    In a 15 to 20 minute office visit, a doctor would not have time to explain such things as “molecular aberrations associated with more aggressive tumorigenesis,” which was one of the other speculations as to why mortality was reduced only for left-sided cancers with colonoscopy.

    I suppose it comes down to the doctor/patient relationship and the patient’s trust and confidence in the doctor – something else that takes time and for which doctors are no longer reimbursed.

  • http://www.TheHealthCulture.com Jan Henderson

    Oops! Make that “The authors cite a case-control study,” not “site.”

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