Colon Cancer Screening Guidelines - Colonoscopy Better Than Sigmoidoscopy? The Truth and the Myth

Colon cancer screening has a particular personal interest for me.  One of my colleagues in residency training had her father die of colon cancer when she was a teenager.

No one should lose a love one to a disease when caught early is often treatable.  Although for both men and women, colon cancer is the third most common behind lung and prostate cancer in men and behind lung and breast cancer in women, it is the second most lethal.

The problem is that patients are often confused about which test is the right one.  Is it simply a stool test?  Flexible sigmoidoscopy?  Colonoscopy?  Virtual colonoscopy?  Isn't there just a blood test that can be done? (No.)

In real simple terms, this is all you need to know. 

All men and women age 50 and older should be screened for colon cancer.  Even if you feel healthy and well and have no family history, it must be done.  Note that Oprah's doctor, Dr. Oz, arguably a very health conscious individual learned that he had a colon polyp at age 50 after a screening test.  Left undetected, it could have cut his life short.  This wake-up call caused him to abort his original second season premier on weight loss and instead show the country why colon cancer screening matters.  He admitted that if it wasn't for the show and the need to demonstrate the importance of screening to America, he would have delayed having any test done.

The least invasive test is a stool test.  If it is to screen for colon cancer, then the test is done at home and NOT in the doctor's office.  Either the fecal occult blood (FOBT) or the fecal immunochemical test (FIT) are available to screen for unseen microscopic blood that could be a sign of a colon polyp or cancer.  Research shows that when done annually the risk of dying from colon cancer can fall by 15 to 33 percent.  If you don't want any fiber optic cameras in the rectum and lower colon, this is the test for you.  You must do it annually.

The next two tests are similar but often confused - the flexible sigmoidoscopy and the colonoscopy.

The flexible sigmoidoscopy examines the lower third of the colon, known as the sigmoid and the descending colon.  Patients cleanse the lower colon by ingesting a small amount of laxative the day before the procedure.  If a colon growth or polyp is found, it can be biopsied or completely removed during the procedure.  The test is typically done in 15 to 20 minutes.  Patients are awake for the procedure and can go home.  Research shows this test can decrease the number of deaths due to colon cancer.  The risk of the procedure is very small with about 1 in every 5,000 patients having a small tear or perforation.  This flexible sigmoidoscopy test is done every 5 years. 

Like the sigmoidoscopy, the colonoscopy also requires cleansing of colon, however, a gallon of laxative is require to empty the entire colon.  Colon growths and polyps can be removed similarly.  Unlike the sigmoidscopy, however, the colonoscopy requires that patients be sedated.  As a result, you will need someone to take you to the appointment and drive you home.  Although the procedure itself takes about 30 minutes, it can be a few hours from arriving to going home due to the anesthesia.  Out of all of the screening tests, it is the most risky with an estimated perforation rate and cause of serious bleeding affecting in 1 in 1,000 patients.  A colonoscopy is done every 10 years.

Would checking the entire colon with a colonoscopy be better than evaluating the lower third of the colon with a sigmoidoscopy?  Evidence that colonoscopies save lives from colon cancer is lacking.  This subtle but important point is often not mentioned in media reports.  Even the NY Times perpetuated this belief that colonoscopy is the preferred test in its January 20th, 2011 article, "Why People Aren't Screened for Colon Cancer."  When family medicine doctor and lecturer in health care policy at Harvard medical school, Dr. John Abramson, wrote a letter to the NY Times editor in February 15th, 2011, noting the this fact in an unrelated article, the American College of Gastroenterology (ACG) wrote a letter indicating that a colonoscopy is their preferred test for screening.

No wonder patients are confused.

If one dissects the ACG letter carefully, we note the following language (words bolded for emphasis):

American College of Gastroenterology’s 2009 colorectal cancer screening guidelines recommend colonoscopy as the preferred cancer prevention strategy, and guidelines by the American Society for Gastrointestinal Endoscopy in 2006 also endorse colonoscopy because of its ability to view the entire colon and remove potentially precancerous polyps, reflecting a strong opinion of these experts that prevention should be the primary goal of colorectal cancer screening.

While public health experts have recently debated the exact parameters to measure the impact of these screening strategies on mortality, a clinical picture that is muddied by the many variables affecting the quality of the examination, the jury is still out. Indeed colonoscopy’s protective power may lie in a growing appreciation that the biology of precancerous polyps and cancer is different in the right compared to the left colon.

In other words, the recommendation is based on opinion.  There is no language indicating that there is evidence.  The "protective power may lie" in such and such, but hasn't been confirmed.  Examples of when doctors made opinions when evidence was lacking only to change their minds later include hormone replacement after menopause, bone marrow transplant for breast cancer treatment, and prostate cancer screening with PSA.

A study that appeared in the Annals of Internal Medicine in the January 6th, 2009 issue, researchers found that colonoscopies did cut down colon cancer deaths, but it was due to detection of the left sided colon cancers (sigmoid and descending colon) and not to the right side, of which only the colonoscopy can reach.  In other words, a flexible sigmoidoscopy would have detected the cancers as well, which has been observed in previous studies. 

Researchers reviewed health records for persons aged 52 to 90 who received a colorectal cancer diagnosis between 1996 and 2001 and died of colorectal cancer by 2003. These patients were compared to a control group who were selected from the population of Ontario and had not died of colorectal cancer.

According to the researchers, complete colonoscopy was strongly associated with fewer deaths from left-sided colorectal cancer. Conversely, the data showed that colonoscopy seemed to have almost no mortality prevention benefit for right-sided colorectal cancer.

So who do you listen to?  I typically review the guidelines from the American Cancer Society (ACS).  As a group advocating cancer screening and awareness, they should have no bias about what test to use to screen for colon cancer.  For individuals at average risk for colon cancer, ACS notes that to find colon polyps or cancer, either a sigmoidoscopy every 5 years or colonoscopy every 10 years.  Their recommendations don't say the preferred option is a colonoscopy.  The Centers for Disease Control the US Preventive Services Task Force, and the National Cancer Institute also say little about which is preferred. 

What does this mean to you?  For those at average risk and no family history of colon cancer, get screened for colon cancer at age 50.  At the bare minimum, do an annual stool test if you don't want an invasive procedure.  Know that at this time there is no evidence that colonoscopy is better than a flexible sigmoidscopy.

If people tell you otherwise ask them to show you the evidence.
And let me know.

Life Line Screening - Worth the Money?

A patient brought in a flyer for Life Line Screening where for $129 an individual can have their carotid (neck) and peripheral (leg) arteries screened for blockage, abdominal aorta for aneurysm (swelling), and osteoporosis. The advertisement claims that "we can help you avoid a stroke" and their logo notes Life Line Screening - The Power of Prevention.

The question is whether having this Life Line Screening test is worth your money?

Short answer? No.

Although the flyer correctly indicates that 80 percent of stokes can be prevented, the National Stroke Assocation does not recommend ultrasound as a screening test. Preventing stroke includes quitting smoking, knowing your blood pressure and cholesterol numbers, drinking alcohol in moderation (if already doing so), regularly exercising, and ingesting a low sodium diet. Their is no mention of an ultrasound test. Why?

Because there is NO evidence that this type of ultrasound testing saves lives in individuals who are healthy and have no symptoms except for the following situations.

The United States Preventive Services Task Force (USPSTF) latest guidelines recommend only screening men between age 65 to 75 years old who have ever smoked to be screened for an aortic aneurysm. If you are in this group, ask your doctor for an ultrasound.

For women, osteoporosis screening should begin at age 65 years old and have a bone density test done. Among the "different bone measurement tests performed at various anatomical sites, bone density measured at the femoral neck by dual-energy x-ray absorptiometry (DXA) is the best predictor of hip fracture." It is unclear how accurate or how good ultrasound of the heel or wrist is compared to the bone density test. If you feel you have other risk factors, like family history, use of steroids for a long period of time, then check with your doctor to see if screening should be done sooner. Otherwise at age 65, all women should be evaluated not with an ultrasound but a bone density test.

USPSTF recommends against screening for peripheral artery / vascular disease (PAD) as well as carotid ultrasound.

Worried about either condition? Ask your doctor. For peripheral vascular disease, particularly when significant, individuals commonly have leg pain when walking. The blockage in the arteries decreases blood flow to the leg muscles when active causing pain. When the person stops walking, the pain resolves. A doctor can determine whether you have PAD by seeing if you have good foot pulses simply by placing fingers on the pedal pulses. If your pulses are normal, then you don't have significant PAD. If the doctor is concerned about your symptoms, he will order an ultrasound which will be covered by insurance.

There is a reason why Life Line Screening in small print writes that they do "not participate in the Medicare program and the cost of [their] screening services is not covered or reimbursable by Medicare" as well as they do "not file insurance claims and the cost of [their] screening services is your responsibility."

There is NO scientific evidence these tests can make a difference except in the specific situations listed above. Since insurance companies and Medicare only want to cover what is proven, Life Line Screening wants you to pay for an essentially unnecessary test.

Better use for your money? Check your blood pressure and your cholesterol. Quit smoking. Cut down alcohol use if you already drink. Maintain a low sodium diet. To prevent osteoporosis, women should take 1200 to 1500 mg of calcium per day as well as 800 to 1000 IU of vitamin D daily.

For $129? Get a really nice pair of walking shoes. Get a pedal exerciser for under your desk. Keep your muscles moving and maintain a healthy weight.

Oh, please don't spend too much money on multivitamins because they aren't worth the money either.

Want more helpful tips? Worry about whether you are getting the best medical care? Does your doctor seemed rushed? Not answering your questions? I have a solution for you!

Breast Cancer Screening with Mammograms at age 40? 50? Who is the USPSTF?

When the U.S. Preventive Services Task Force (USPSTF) updated their recommendations and were against routine mammography for women aged 40 to 49, it certainly got a lot of attention. These guidelines are far different than those advocated by the American Cancer Society (ACS) which recommends screening starting at age 40 with annual mammograms.

• Who is the USPSTF?
• What does their recommendations mean for women?
• Why is there conflicting recommendations?

Who is the USPSTF?

The U.S. Preventive Services Task Force (USPSTF) is an independent committee of primary care and preventive physicians that periodically reviews the latest medical research and recommends tests and screening methods that have scientifically been shown to make a difference. As a result, its recommendations are the most conservative of any national organization.

The USPSTF’s recommendations are considered the “gold standard” for determining which clinical services are preventive. They review and look at various screening tests and preventive medications to determine whether there’s proof these interventions work and that the benefits they provide outweigh the potential harm. USPSTF indicates how strongly it recommends a particular method with a letter grade designation (A, B, C, D, and I). An A recommendation means that USPSTF strongly recommends that doctors provide a particular service to eligible patients. A B rating is simply a recommendation. A C means the task force recommends against routinely providing the service, but leaves the decision to the discretion of the individual doctor and patient. A D rating means the group recommends against providing for a particular intervention. An I recommendation indicates that there is not enough evidence to determine whether to recommend for or against a particular procedure.

The USPSTF recommendations tend to be the most conservative of any national organization, because they look for interventions that have proven benefits backed by research. Therefore, promising new technologies and tests that are yet unproven (and at times remain unproven or shown to be no better than existing tests) will not be recommended. As a result, the USPSTF’s guidelines may lag behind those of other organizations. But because they set such a high standard before recommending a particular treatment, insurers should cover the tests and procedures rated A and B.

From the November 2009 update on breast cancer screening update, the USPSTF recommended:

• Against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. Grade: C recommendation.
  

• Recommended biennial screening mammography for women aged 50 to 74 years. Grade: B recommendation.
  

• Current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. Grade: I Statement.
  

• Against teaching breast self-examination (BSE). Grade: D recommendation.
  

• Current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. Grade: I Statement.
  

• Insufficient evidence to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. Grade: I Statement.

What does this mean for women?

First, that there is some evidence that screening between ages 40 to 49 for breast cancer among women with average risk may not be as beneficial as we previously thought. There has been evidence from other countries, like Canada, which have suggested that. However, it is highly unlikely that the American Cancer Society (ACS), being an advocacy group for cancer awareness will change their stance. They said as much with the following:

The USPSTF says that screening 1,339 women in their 50s to save one life makes screening worthwhile in that age group. Yet USPSTF also says screening 1,904 women ages 40 to 49 in order to save one life is not worthwhile. The American Cancer Society feels that in both cases, the lifesaving benefits of screening outweigh any potential harms. Surveys of women show that they are aware of these limitations, and also place high value on detecting breast cancer early.

The American Cancer Society neglects to mention the potential number of extra women harmed with the extra screening between age 40 to 49. An additional 565 women need to be screened above and beyond the 1,339 women to save one life. Within this additional group, many women will have abnormal mammograms and require breast biopsies only to discover that the results were normal. The mammogram was a false-positive.

The USPSTF found in a study in the Annals of Internal Medicine, funded by the National Cancer Institute, that screening every other year achieved over 80 percent of the benefit of screening annually while cutting the false-positive result by nearly half. While every other year screening from age 50 to 69 years resulted in about a median 16.5% (range, 15% to 23%) decrease in breast cancer deaths compared to no screening, starting mammogram at age 40 decrease the death rate further by 3 percent, but increased the costs as more false-positive cases occurred. This article helped influence their recent decision.

Realistically for women, since ACS will not change their recommendation, is that mammograms will still be a covered benefit for any woman who desires to have a mammogram as early as age 40 and can be repeated annually.

What does this mean for you? If you are worried about breast cancer, consider getting screened starting at age 40, however, the benefit of screening may not be as good as we first thought. Certainly if there is a family history of breast cancer, you should discuss with your doctor whether mammography is enough or whether a breast MRI is needed.

Why are there conflicting information?

This won't be the first time USPSTF will have different recommendations than groups like ACS or other professional medical associations. Reasonable doctors and researchers can look at the same data and have different results. It speaks to the problem of screening for cancers and the tools that we currently have. The amount of precision that we would like as patients and doctors in identifying which group of individuals truly need a screening intervention and who does not have yet to be discovered. USPSTF and ACS disagree a bit on colon cancer screening as well. For example, when it comes to colon cancer screening USPSTF gives a grade A recommendation and suggests that:

Using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods may vary.

Yet, ACS also recommends virtual colonoscopy or stool DNA testing as reasonable alternatives even though there is no proof they save lives.

Stay tuned. Medical science continues to evolve and recommendations continue to change. The the mean time, exercise regularly, don't smoke, eat five servings of fruits and vegetables daily, and you might extend your life by an additional 14 years!

Your most crucial and trusted relationship is between you and your doctor. Questions? Speak up and ask. Don't be scared. Be informed.

Eight Tests That Could Save Your Life - Forbes

Refreshing to see this article in the recent June issue of Forbes titled Eight Tests That Could Save Your Life. It's the boring and unsexy stuff that we need to focus on, like maintaining a healthy weight, lowering blood pressure and cholesterol, getting cancer screenings done, and screening for diabetes. Using the US Preventive Services Task Force guidelines, this piece is anchored is in the science and not theoretical hype of whole body scans and genetic testing.

From the article:

• If you're healthy and trying to stay that way, the important tests are few and relatively low-tech: Measure your cholesterol, step on a scale, check for signs of a small number of cancers and tell your doctor if you feel depressed.
• 
  This advice may run contrary to what might be characterized as "test madness"--the tendency of doctors and patients to want to test in all sorts of ways, using dozens of parameters that purport to measure how well your internal bodily engine is running. More are proposed and touted by entrepreneurs all the time--such as exotic new genetic tests and whole-body scans. They claim they will spot disease before symptoms arise. But most have no data proving that taking the test will improve your health or lengthen your life.
  

Absolutely true about the "test madness". We'd like to believe that more tests and scans are better when in fact there is no evidence that is the case. This article is far different than others aimed at the high net-worth individuals which convince them that executive physicals can save lives (perhaps anecdotally, but not significantly).

Kudos to the authors and Forbes for publishing the truth and not falling into the allure of the hype. If more Americans worked on these simple common yet vitally important measures, then we as a nation would be far healthier and spend less than we do today.

Medicare Won't Cover Virtual Colonoscopy - the Right Decision

In a clear blow to CT device manufacturers like General Electric, the Centers for Medicare and Medicaid Services (CMS) has decided not to cover virtual colonoscopy, which is a non-invasive way of screening for colon cancer.

It's the right decision. Although virtual colonoscopy was recommended by the American Cancer Society (ACS) as a reasonable alternative to the more invasive flexible sigmoidoscopy and colonoscopy, the issue with virtual colonoscopy is radiation exposure when other ways of screening already exist. Certainly from the perspective of ACS, which is an organization focused on increasing cancer screening and awareness, I understand the reason for adding virtual colonoscopy as an option.

But in the reality of the healthcare crisis and the goal of President Obama to make healthcare more affordable for all, decisions like this are inevitable where someone won't be happy with the outcome, in this case CT device manufacturers. With the announcement earlier this week that hospitals, insurers, doctors, device manufacturers will decrease the rate of health care expenses by 1.5% per year over the next decade, tough decisions will be made. Private insurers often follow CMS decisions, so don't expect to have virtual colonoscopy covered by your insurance company to screen for colon cancer.

The funny thing is this decision by CMS will be one of the easier decisions to make because other, although less comfortable procedures exist to screen for colon cancer. (Note that the preparation for all three procedures is the same. One needs to take a laxative to clear the colon of stool so that colon polyps can be visualized).

The other is that CMS will be using guidelines from the US Preventive Services Task Force in basing decisions. USPSTF bases recommendations on scientific evidence and tends to be the most conservative of any organization, like the American Heart Association, American Cancer Society, and various physician organizations.

CMS left the door open for reconsideration of virtual colonoscopy in the future, which is reasonable. Certainly the technology may evolve where radiation exposure is minimal to justify exposing people of average risk to a modality that potentially could increase other forms of cancer.

Review my March entry - Virtual Colonoscopy - Just Say No.

The entire article from the Associated Press follows:

Tue May 12, 10:18 pm ET
WASHINGTON – Medicare won't pay for the so-called virtual colonoscopy procedure, concluding Tuesday that there's inadequate evidence to support the cheaper, less intrusive alternative to the dreaded colonoscopy.
Some experts had hoped that popularizing the X-ray procedure would boost screening for colon cancer, the country's second leading cancer killer. Screening to spot early cancer or precancerous growths has resulted in fewer deaths over the last two decades.
But in a decision posted on its Web site, the Centers for Medicare and Medicaid Services said that the test does not qualify for Medicare coverage. The memo noted that the procedure is performed on people without symptoms and cannot, in itself, rid a patient of precancerous growths, like a regular colonoscopy can.
Medicare does cover regular colonoscopies, in which a long, thin tube equipped with a small video camera is snaked through the large intestine to view the lining. Any growth can be removed during the procedure.
CT colonography, also known as virtual colonoscopy, is a super X-ray of the colon that is quicker, cheaper and easier on the patient, but involves radiation. Both procedures involve preparation to clean out the bowels.
The Medicare memo notes that the virtual colonoscopy has shown better precision in detecting larger polyps than smaller ones.
There's been some division of opinion in the medical community over the virtual colonoscopy. Some doctors question its utility since, if a polyp is found, a regular colonoscopy would typically have to follow, anyway.
Others support it, saying it can result in early cancer detection. The American Cancer Society recommends it as an alternative to a regular colonoscopy.
A concern for Medicare officials, according to their decision Tuesday, was the effectiveness of the procedure for the Medicare population — people 65 and older — as opposed to younger patients. More data is needed to answer that, Medicare said.
The U.S. Preventive Services Task Force opted last fall not to give its stamp of approval to the virtual colonoscopy, citing the risk of radiation among other factors. Medicare said it took that decision into account in reaching Tuesday's determination, which is final.
Some private insurers cover the virtual procedure but others don't. Colonoscopies cost up to $3,000 while the X-ray test costs $300 to $800.

Routine Annual Physical - Not Worth the Time or Money

A recent article in the September 24th issue of Archives of Internal Medicine found that routine annual physicals may not be particularly useful. Although these types of visits account for 1 in 12 doctor office visits, the study found:

• only 19.9 percent of eight preventive services were provided at these examinations as opposed to other types of physician visits.
• only 8.8% of weight reduction counseling occurred during these visits.
• obtaining mammograms, checking for cholesterol, and recommending patients quit smoking occurred at more than half of these encounters.
• individuals in the Northeast 60 percent more likely to receive a routine physical than those in the West. (Note a recent study in Health Affairs also found that health care costs per capita were higher in the Northeast).

"We need to question encouraging everybody to come in for an annual physical," Dr. Ateev Mehrotra of the University of Pittsburgh School of Medicine and the RAND Corp., who led the study, said in a telephone interview.

"There's a lot of money, a lot of visits, a lot of adults going to see their doctor for annual physical exams with a real unclear benefit. It's the No. 1 reason adults see their doctor, and yet we don't know whether it's helpful or not," he added.

This is hardly a surprise. The value of having a routine physical is no more beneficial in finding problems than having your mechanic check your car, which runs completely fine, annually just in case. For decades, there has been no scientific evidence that an annual physical helps save lives. For those who are otherwise healthy, don't take prescription medications regularly for high blood pressure, diabetes, cholesterol, asthma, emphysema, or other potentially serious medical problems, there isn't much gained from a "check-up".

That should not, however, mean that individuals should avoid doctors either. Like you car which has a maintenance light which indicates servicing is required, patients must have tests that screen for various medical problems and cancers based on the age and gender of the patient. For example, all women without a family history of breast cancer should have a mammogram starting at age 40 and repeat every one to two years. While this screening could be done during an annual physical, the screening could be done at any other future visit. The study showed that many of these preventive interventions occurred at other office encounters.

Find out what tests you are due for at the U.S. Preventive Services Task Force. It is a good start, but not the final word. Check out other organizations like the American Cancer Society, the American Heart Association, and the American Diabetes Association as well.

If having an annual physical helps remind you that certain tests should be done to stay well then continue the practice. Otherwise, save your time and money. Figure out what tests you do need depending on your age and then get them done - no routine annual physical necessary.