What’s scarier than a colonoscopy?

What’s scarier than a colonoscopy?

Colorectal cancer.

Shudder. That’s the knee-jerk response that most of my patients give me when mention of their 50th birthday creeps into the conversation and I reveal that it is time for their screening colonoscopy.

Admittedly, a colonoscopy is not an experience that the overwhelming majority of the human race embraces with excitement and anticipation. Instead, it is a life event that is filled with dread, fear, annoyance, avoidance, and any other unsettling thought that you should feel free to insert here (____) like a game of Mad Libs gone terribly awry.

But importantly, this life event is life-saving. I repeat: life-saving. It is crucial to emphasize that in about 95% of people, colorectal cancer is a preventable cancer. And sadly, it is still the number two cancer killer amongst Americans today. And the question is: Why is this so?

First off, the fear of the unknown is powerful. Not knowing what to expect before, during, and after the procedure is a completely understandable concern, which is why it is so important to be well-informed, and to dispel any myths about the procedure. After having a detailed discussion about the benefits of a colonoscopy, as well as the risks of the procedure itself and the sedation we provide (unless you opt for no sedation, which of course can be done), it is then that you ought to turn to someone you trust for more information.

I always encourage my patients to talk to their friends and loved ones who have undergone the procedure to get the nitty gritty details about the goings-on of the colonoscopy, from start to finish. I find that once the procedure is over and done with, most patients will attest that it wasn’t nearly as dreadful as they anticipated. Importantly, they are relieved that despite their fears, they had it done and have been properly screened for cancer.

And I always remind patients to please spread the word about this attestation, because colonoscopies plainly and simply save lives. Not only does it allow for colon and rectal cancers to be caught early, which ensures fantastic survival rates compared to some of the other cancers people suffer from, but a colonoscopy also detects precancerous lesions called polyps. In most individuals who have been diagnosed with colorectal cancer, the cancer derived from a polyp, which on average, takes about 7 to 10 years to grow into a cancer. A colonoscopy can stop this chain of events dead in its tracks, as the goal of the procedure is to remove polyps in real time, thereby preventing a cancer from occurring. In other words, despite some of the negative press it gets, a colonoscopy is the most sensitive and specific test we have available to us to prevent colorectal cancer.

But it’s not just the fear of the colonoscopy itself. Truthfully, it’s the preparation the night prior that is the primary source of disgust and disdain. The thought of guzzling the less than palatable jug of solution is no picnic. But thankfully, studies have shown that by splitting the preparation solution into two doses, one taken the evening prior to the colonoscopy, and the remainder of the preparation the morning of the colonoscopy, makes for a safer, more effective procedure. Also, splitting the preparation allows patients to consume less volume in a given sitting. Is it the most pleasant of experiences? No. Is properly taking the preparation a necessary evil to ensure an effective and complete examination of the colon? Yes (insert expletives here). Until someone cleverly concocts a colon preparation that is refreshing and tasty, we’re sadly stuck with what we’ve got (which thankfully, has already significantly improved over the past decade or so).

With that said, the best test to prevent colorectal cancer is the one that gets done, right? So if you fear a colonoscopy with all of your might, there are alternatives available, and you should certainly discuss them with your doctor to see what is right for you. But please, if you’re getting ready to blow out those 50 candles on your birthday cake, take that day and half to dedicate your time to the preparation and that screening colonoscopy in order to help yourself and your loved ones. Importantly, if you have a family history of a 1st degree relative with colorectal cancer or colon polyps, talk to your doctor about getting screened, because you should be screened earlier than the average-risk individual.

And remember, as scary as a colonoscopy may seem, and as unpleasant as you think the preparation for it may be, think about the risks and worry that come with the very real potential alternative to not getting screened – being diagnosed with colorectal cancer. Now that’s scary.

Sophie M. Balzora is a gastroenterologist and can be reached on Twitter @SophieBalzoraMD.

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  • http://www.dpsinfo.com LaurieMann

    I dislike them (and I had to have one in my 40s to ensure the irritable bowel syndrome was only that) and am a huge coward around getting them. That said, I’ve had at least one polyp removed each time, so I look at a colonoscopy as my colon cancer insurance policy. The two-step prep is a little easier than prep was back in the 90s.

    • Sophie Balzora, MD

      Great comment! Your honesty is appreciated, and I think it will help urge others to be proactive about having their screening colonoscopy when they too turn 50!

      • http://www.dpsinfo.com LaurieMann

        I also ran into a Website where people were complaining a lot about Versed, which is typically used as sedation for colonoscopies. I had no issues with Versed – in fact, I’ll admit I felt high after the first time I had it, though not after the subsequent times. Some people do have a bad reaction to anesthesia, and it seems to be worse depending on the age of the patient. But most people do not have lasting bad side effects to anesthesia or colonoscopies.

        • Mary Corwin

          Diprivan seems most common for the procedure. The whole thing is painless and efficient but I agree with the contributor who stated the big deal is embarrassment. I shudder and blush just thinking about it. Plus I have heard nurses make jokes about the scope being “the choo choo train” as it advances.

          • Guest

            Embarrassment, and also the fear of being sexually assaulted through being used for students to practice unnecessary intimate exams on without your knowledge or consent. That’s horrible to think of being knocked out,completely helpless and vulnerable, and strangers can line up and do whatever they like to you and you’d never know but you’d wonder why you were so sore afterwards.

  • Mel Lewis

    So why don’t they do them in France? Doctors here claim it is an ‘invasive’ procedure with a degree of risk not justified for routine screening. They advocate the hemocult test for blood in the tool and only perform colonoscopy in case of a positive test result. It is just health economics or this a legitimate stance?

    • SBornfeld

      The recommendations are changing–and apparently the flexible sigmoidoscope is again being considered among the options for bowel screening.

      I’m frankly surprised to hear that colonoscopy is not considered for screening. Is there any actual recommendation by an official agency favoring occult blood over colonoscopy for screening? I’d like to see it.

      • M.K. Caloundra

        Bowel cancer (cancer colorectal) in France: primary screening is via stool sample, secondary is via colonoscopy:

        “A free test is available to all men and women aged 50 to 74 every two years. Your GP will provide a kit for taking a faeces sample at home, which is then sent in a pre-paid envelope to the local testing centre (centre de lecture) to check for blood.

        “The standard €22 cost of the GP’s consultation is reimbursed at 70%.

        “You and your doctor will both receive a copy of the results. If an anomaly is detected, you will be referred to a gastroenterologist (gasto-entérologue) for a colonoscopy (coloscopie).

        “This usually takes place in hospital, under general anaesthetic and requires you to turn up à jeun (without eating, drinking or smoking beforehand). This makes early morning tests ideal.

        “The colonoscopy will cost up to €180, plus €18 for the hospital stay. Again, all of this is reimbursed by the Assurance Maladie at 70%.”

        See http: //www. connexionfrance. com/cancer-screening-france-costs-jargon-explained-10761-news-article. html
        (remove spaces from URL)

        • SBornfeld

          Thank you. We do not have statutory guidelines in the U.S., and our USPSTF calls it’s recommendations “advice”, but it’s clear that it’s quite likely this will become a factor in reimbursement policy.

          I have not looked specifically for comparative outcomes for bi-yearly stool guaiac vs. colonoscopy q 10 years, or anything like that–the literature may well exist.

          • Mel Lewis

            I’d be interested in hearing about any data that shows comparative outcomes of colonoscopy vs. stool samples. France’s health economics policy is anything but transparent. It’s hard to ‘demand’ an unpleasant and costly test if you’re told it’s not needed.

  • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

    Another reason that sometimes people won’t get the test done is because of the cost to them. Even though the screening colonoscopy may be covered at 100% the cost for the prep that is involved is very costly. Some doctors use Miralax as part of the prep, and that stuff is very expensive. When someone is on a very tight budget these preventive screenings where prep is involved one must make the decision of which is more important: to eat and keep a roof over their head, or have a test that can catch something early and then run the risk of needing further testing and procedures which also costs money that they may not have. A relative of mine was supposed to have had a colonoscopy at the end of last year because the doctor found a symptom of concern. Problem is that because this was not a preventive screening colonoscopy the issue of the deductible and the coinsurance, and other fees now came in to play. So that would have created some other problems on the financial front because now it’s an additional cost they couldn’t afford. Did they have the procedure done? Nope.

    • http://www.facebook.com/people/Frank-Lehman/100002241640186 Frank Lehman

      Miralax is expensive? On the internet Wal-Mart offers the 7 dose version for $5.94 plus shipping. You can nearly pay for that just by considering the cost of the food you don’t eat while preparing for the procedure.

      • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

        I know what you are saying. And unfortunately for those on a tight budget even $5.94 plus the shipping cost is expensive. This is a real problem for some people.

        • Guest

          $6 once a year is two cents a day. If you’re not willing to spend two cents a day on potentially saving your own life, then there’s no helping you.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            True, but there truly are some people that can’t afford that $6 once a year. As I just said to Suzy there are people who are so impoverished that even $1 is too expensive. It is not a good thing, but that’s the way it is for some people. It’s one reason why you see that there are so many people in this country who go without healthcare and only get help when it’s critical (something we talked about in my Nursing Fundamentals class the last couple weeks including today).

          • PCPMD

            … if you can’t afford $6/year, you’re poorer than a street bum, and are likely in the lowest 0.00001% of the population. While I have some (small) sympathy for a person in that category (assuming that they also don’t have a church/friend/relative/stranger who can help them out), I don’t think it represents a statistically significant portion of the population, and therefore is a meaningless interjection to this conversation.

          • Guest

            You’ve been spending WEEKS in a “NURSING FUNDAMENTALS” class on the horrible UNFAIRNESS of asking people to kick in two cents a DAY to their own SURVIVAL?

            This is why nurses cannot take the place of doctors. This is not science, this is not medicine. This is ideology and pure silliness.

        • Suzi Q 38

          Kristy, I know that it is expensive for some people, but is there a generic Miralax that is cheaper?

          Also, if they let their immediate family know, I am sure that someone could go down to Walmart and donate a bottle to them. I would for any family member.
          Sometimes, if you contact the company and let them know about their financial situation, they will send coupons worth several dollars per bottle.

          Maybe they have some samples that they can send. They probably would not need a whole bottle.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            Suzi, that’s great that there is a generic form of Miralax but some of those generics are also very expensive as well.
            As far as that if someone let their immediate family know they need help then that family member could help them out such as through a donation, nice idea. But not everyone’s family is willing to do that. That’s good that you would be willing to do that, but not everyone is as I say.
            I am not saying that it is ok to skip tests to try and prevent bigger problems, but if someone truly can’t afford to do it they can’t afford to do it. Even $1 is too expensive for someone if their budget is that tight. These would be the ones in extreme poverty, and yes there are plenty like that in this country as I learned in my Sociology class that I had to take before I got in to the heart of my Nursing program.

      • Suzi Q 38

        Better yet, just drive down to a Wal-Mart.
        Ask a neighbor for some coupons.

      • Guest

        People have become so entitlement minded, they think that EVERYTHING should be 100% FREE, i.e. paid for by someone else. Even $6 a year is UNFAIR to ask them to pay for their OWN HEALTH.

        Goodness me, they can buy soft drink and cheezls with their EBTs, but not a generic bottle of Miralax?

    • Mengles

      And Obamacare is supposed to solve this how?

      • Disqus_91O716

        Keep Obama in President, you know, he give us a phone, he give us free Miralax, we don’t need to worry about paying our mortgage or putting gas in our car, it all FREE.

  • Anthony D

    What’s scarier than a colonoscopy?

    The medical bill that you get after the procedure!!!

    • Mengles

      You are free to shop around or do your own since it is an elective procedure.

      • Noni

        Umm…not really. There’s no transparency in health care, so comparing prices is not as easy as it seems. And don’t forget those pesky facility fees!

    • QuardeMD

      colonoscopies could be cheaper. Cost less than a 70USD in some countries. These insurance companies are driving the cost of healthcare sky high. I feel sorry for all of us (physicians and non physicians alike)

      • Guest

        They cost around $235 in France, about $165 of which is covered by insurance… so about $70 out of pocket. No one complains that that is not affordable, yet you have American nurses on this very blog complaining that because a $6 bottle of Miralax is not “free”, patients cannot afford this procedure. The American insurance situation, and the way so many otherwise intelligent people demand that it cover 100% of everything (and then never worry about what anything costs because it’s all “free”), is worrying.

  • YomiPharmD

    I am a 24 Year old PharmD who had severe abdominal pain occasionally for 8 months. When I saw blood in my stool, I went to my PCP and he did a guac which was positive so he sent me for a colonoscopy. During my colonoscopy they found a tumor that was eventually classified as Stage 3C. I had surgery and 6 cycles of FOLFOX and have been cancer free for 2 years. Although some may consider me to be a rare case, I think a colonoscopy as a preventative measure is more reasonable than any of the alternatives.

    • SBornfeld

      Yowee! Age 24–a credit to you and your PCP for not poo-pooing these symptoms in one so young.

      I understand that the USPSTF recommendation is as a “screening” test; I fear that their recommendations are being generalized to a recommendation NOT to test outside of the age parameters.
      Your experience once again demonstrates that you “treat the patient, not the textbook”.
      I wish you a long, happy life!

      • YomiPharmD

        Thank you sir for the kind words! I am make the best of everyday for myself and my patients.

      • QuardeMD

        the USPSTF recommendation (for screening at 50years) is for the general population without any prior GI symptoms. Mr. Yomi had an eight month history of recurrent abdominal pain associated with bloody stools. That qualifies him for a screening colonoscopy irrespective of his age. So the PCP did what is expected medically (textbook wise)…:)

        • SBornfeld

          Certainly his history is an indication for colonoscopy. But even you slip and call this a “screening” colonoscopy, which of course it is not–it is diagnostic. That’s exactly the confusion I’m concerned about.

  • Guest

    Obamacare is mandating that insurance companies make yet another thing “free” … which is why health insurance premiums are skyrocketing. SOMEONE has got to pay for all these “free” things after all.

    PJ O’Rourke: “If you think health care is expensive now, wait until you see what it costs when it’s free.”

  • Jean Oliver

    While I understand the thinking and evidence that colonoscopies are best at preventing colon cancer (rather than just early diagnosis) because of the ability to remove polyps I still think the medical community is doing patients a disservice by stressing this test as the best or only option. Yes, it is expensive and not actually “free” as we pay for it with our ever increasing premiums. (Another reason those premiums keep going up: more and more expensive screening tests to more and more people, etc.). And I do also resent a bit the lack of true information on those colon polyps, such as the likelihood of them actually becoming cancerous. I have found information that states the vast majority of those polyps, especially the most common small tubular adenomas, will never progress to cancer. It is also a disservice to patients to put forth the idea that every one of these polyps will become cancerous. Some people may be able to live with the small risk or may be more willing to undergo the FIT test (as the person stated they do in France), then only go on to colonoscopy if they get a positive result. This would be a more cost effective approach, also, and after all we do not have an infinite pool of resources.
    One more point that doctors rarely acknowledge: some patients dread the embarrassment more than the procedure: the thought of being “out there” in a room full of people is distressing, to me anyways. Perhaps if they addressed this by offering patients a same gender team and/or disposable colonoscopy shorts it would help more people be willing to undergo the exam. A choice in sedation (or not) would also be great: most doctors do not offer a choice; it’s either get what we offer or don’t get the test.

    • Guest

      The thought that anesthetized patients have been, without their knowledge or consent, repeatedly subjected to genital, anal and breast examinations by medical students, puts me right off.

      http: // www. naturalnews. com/031155_medical_students_anesthesia. html

      http: // www. foxnews. com/health/2011/01/28/medical-students-examine-unconscious-patients-consent/

    • Sophie Balzora, MD

      As mentioned in the article, “the best test for colorectal cancer is the one that gets done” both correctly and at the appropriate intervals. So, colonoscopies are certainly not the only option for screening, but it is the best we currently have available to prevent colorectal cancers, with a reduction in colorectal cancer mortality by over 50%, which is significantly higher than other modalities. However, it is unfortunate if patients have had the experience of not having all of the screening options explained to them thoroughly by their physicians, as well as the different sedation options available if a colonoscopy is the chosen test. Clearly this is an important issue that speaks to the breakdown in physician-patient communication that begs for improvement in the long-term.

  • buzzkillerjsmith

    You have to die of something, but you don’t have to die of colon cancer. Get scoped at age 50.

  • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

    As I said before, if someone is on a very tight budget they can’t afford to get Miralax period regardless of how much it costs. And yes, that’s all well and good that the preventive test is covered at 100%. However, if that test finds something and more tests need to be done those other tests are not covered at 100% and the deductible and the coinsurance comes in to play. Same with the treatments for the cancer when it is found.

    • Guest

      Should we demand that the Government withhold two cents a day from welfare/medicaid/medicare recipients’ welfare checks and then give them a “free” six dollar bottle of generic miralax once a year?

      How paternalistic do we need to get here?

    • Mengles

      You obviously don’t understand how insurance works.

      • Disqus_91O716

        Her car insurance obviously pays for 100% of all petrol, maintenance and running costs including annual tune-up and any minor repair work necessary; and her home insurance pays to have her gutters cleaned, her windows washed, her gardens maintained and her HVAC and other appliances to be inspected annually.

        All “for free”.

  • Sophie Balzora, MD

    Definitely a lot of food for thought here, which is wonderful! The goal of this piece is to raise awareness about colorectal cancer, the fact that it is a preventable cancer, and thankfully, there are many modalities available to us for screening, the best of which is colonoscopy. In the end, it’s about the patient and physician working together to figure out which option for screening is best for the patient based on the patient’s preferences and beliefs. So regardless of which method you choose, the most important thing to remember is to get screened. It can safe your life…

  • Guest

    they let students perform unnecessary exams on male patients as well, see the links in the comment in reply to jean oliver below.

  • SBornfeld

    Of course. But the colonoscopy is no better than the doc holding (and reading) the scope.

  • Drew

    I had not envisioned nor did I welcome a colonoscopy, but on the maybe slightly pushy advice of my internist, I overcame my qualms and did it for screening as recommended. A large carcinoid was removed. Fortunately, it had not spread and 8 years later, I’m clean. A year ago, my half-brother wasn’t so fortunate, dying at 59 from colon cancer just a couple of months after it was discovered. I thank my doctor every day that I get to watch my daughter grow up and thank you, Dr. Balzora.

    • Sophie Balzora, MD

      Drew – I’m so sorry to hear about your half-brother. It is true that sporadic cases of colorectal cancer exist, and frankly, everyone is susceptible to it. I’m glad that you were wise and screened for colorectal cancer at the appropriate age, and that you can now spread awareness about the disease and the importance of getting screened. Kudos to you, and to your internist for having that life-saving discussion with you! Thanks for sharing your story.

  • Ellen Mary

    Can anyone on here comment on timing colonoscopy around pregnancy & extended lactation? My family history includes polyps and there is colon cancer in a 2nd? degree relative (uncle), so I do wish to be screened (still a little unsure about whether wounds to the colon are super healthy . . . ) but plan to be lacatating into my early 40s . . .

    • Dr. Jess

      That sounds like something you should ask your own doctor, not a herd of blog commenters you’ve never met, about.

      • Ellen Mary

        Thanks champ! I wasn’t asking for professional medical advice, I was seeking GENERAL comments on the issue of timing Colonoscopy around Pregnancy & Lactation. I just happened to give a little background on my reasons for asking after that. I am fully versed in accessing medical opinions, but it might surprise you to learn that very few medical professionals know very much about Lactation @ all, and OB/GYNs don’t usually involve themselves with Colonoscopies. Peace.

  • QuardeMD

    The idea of colonoscopies is met with a lot of patient resentment primarily because it involves a very personal and in some respects less talked about part of the human body. The benefits of scheduled colonoscopies far outweigh the risks. Physicians will have to take a greater share of the burden here by educating patients on the potential benefits. Hopefully with time patients will mention colonoscopies without any fears or reservations….

    • guest

      Patient modesty, and the (in some documented cases, justified) fears of being knocked out and then, once naked and vulnerable, being “practiced on” by unknown quantities of students, without consent or even being informed afterwards, is a real sticking point.

      And then there are medblogs where prospective patients can read how nurses and others make fun of their unconscious patients, that’s not reassuring either.

      Somehow the medical system has to earn back the trust. Maybe videotaping all procedures so that patients can reassure themselves that nothing “off” happened to them once they were put under would help.

      • Sophie Balzora, MD

        I think that this important issue speaks more to a lack of professionalism in the workplace in general than to colonoscopies under sedation specifically. However, I certainly agree that professionalism in medicine is sometimes underappreciated, yet so important. Having a mutual trust between physician and patient is truly essential, and vital, to a given patient’s adherence to medication regimens, healthy lifestyle practices, and the like.

  • Cyndee Malowitz

    I have a friend who just had one and she was wide awake! She watched the procedure and she said it was only mildly uncomfortable. So, I’m planning on going to the same physician, not so much because I want to view the procedure, but because I hate needles/IVs!

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