This study reminds me that colon cancer screening is a decision, like all healthcare decisions, to be made by a patient in consultation with his or her physician.
"Colonoscopy actually prevents cancer. A precancerous polyp that is removed poses no threat of mutating/growing into a cancer."
How do you know that the precancerous polyp is not just a manifestation of an underlying cancer, in which case its removal may only slightly mitigate the risk for future disease.
What is the rate of conversion of precancerous polyps to cancerous? Do we have any idea? My old dermatologist used to say “the only good mole is a gone mole” and he made a lot of money through sharing that message with his patients. Unfortunately, he missed melanoma on my friend and it was not associated with a mole!
Surely you have seen harms from colonsocopy during your career? I know I have. Perforations requiring surgery. No deaths that I am aware of. but the cost is huge and that is a potential harm if those resources of money and time were spent elewhere. Also, why compare colonoscopy to doing nothing. Isnt the comparison to sigmoidoscopy or FIT test?
My brother-in-law had a perforation from a colonoscopy a year ago. He was very sick, in the hospital for two weeks, at a cost of several hundred thousand dollars. These risks need to be accounted for in the analysis. A minor point: with a risk reduction ratio of 0.31%, isn't the number to screen the inverse: 323?
Related question popped up for me - is there a way to learn if a health system grades their docs on screening compliance? I changed insurance & health systems (from Kaiser to UW) over the past couple of years and the mammogram guidance to me personally in conversation has differed (still "shared decision-making" but I definitely felt persuaded in different directions). Most recently I agreed to the referral but haven't scheduled - and I'm even getting follow up texts, notes in MyChart, calls. Would love to know if part of the "encouragement" to screen is to meet quotas. I have lower than average risk per various assessments.
Oct 17, 2022·edited Oct 17, 2022Liked by Adam Cifu, MD
So, some easy math here.
Per your comment: “ For those of you who like the “number needed to screen.” These numbers equate to a number needed to screen of 263 to prevent one colon cancer. For a patient, there is a 1/263 chance that your colonoscopy will prevent a cancer.”
263 x $3000 average cost/charge = $789000 or put another way, over $$3/4 of a million dollars all burdened on the taxpayer (Medicare/Medicaid) and/or the insurance premium “payer”.
The studies we need are how to reduce the overall cost burden and actually support/protect patient’s quality life years through lower cost, equally effective “screening “ tools/tests/screening algorithms.
Also not considered here are the patient’s costs as well (prep, lost work, general productivity declines for days, family burden, emotional, etc).
We all want perfect health, and allopathic medicine promises to provide the illusion that it’s possible with all the magic elixirs of “modern” medicine.
My bias of course is I’m medically conservative and also look at cost to benefits (maybe too much).
"I am an avowed medical conservative who thinks that a doctor’s role is primarily to treat disease."
I winced at that statement. I don't want a doctor--any doctor--to _primarily_ treat my disease. I want the doctor to primarily seek to understand and fix or improve the underlying cause(s), and only secondarily treat the disease/condition, either in the interim or because the underlying cause isn't treatable. In any case, in addition to standard medical interventions, I want the practitioner to work toward whole-body health with diet, lifestyle, and nutrients - not just with drugs and endless tests.
Unfortunately, education in diet, lifestyle, and nutrients is woefully lacking in medical schools, and most practitioners are not only uneducated in these interventions, but also unsympathetic, even hostile, to patients who research and implement such approaches on their own. I strongly advocate the integrative approach--taking the best of both worlds, and neither one to the exclusion to the other.
Why not do cologard for general screening, then build a case for more invasive procedures if family history and risk factors (smoking, obesity etc) are present? I appreciate the polyp argument but not all polyps become cancerous. It seems that the point of the recent study was that colonoscopy, as a one-size-fits-all approach, is not warranted.
It is evident that your patients trust and respect you, Dr. Cifu, and that is to your credit.
I am curious as to your opinion on Cologuard for younger, low risk patients who are considering postponing or foregoing colonoscopy due to prep/schedule/anesthesia or other concerns, clearly as just a true screening test. Thoughts?
The writer states "I am an avowed medical conservative who thinks that a doctor’s role is primarily to treat disease.[i] Anything that has the potential of turning a healthy person into a patient should be examined in a very bright light." Then why doesn't she and all doctors tell patients to remove meat and refined food from their diet since they are a strong contributors to colon cancer.
As an oncologist, I value this nuanced approach. We should also not forget that a flexible sigmoidoscopy is a reasonable, less costly and convenient option. Earlier studies have supported the likelihood that screening benefits arise from finding left sided colon lesions, which is what a flex sig does.
The RCT clearly shows we do not fully understand all of the factors impacting overall mortality. The non-significant difference in colon cancer death is particularly telling - how could this be? Is it possible that the procedure accelerates this outcome in a similar fraction of patients as it prevents? To improve either the procedure itself, or overall care, this should study should be viewed as a challenge to find the answer.
Another issue which has not been addressed in this whole debate is how often to screen - I recall a physician I worked with saying that he believed that if a person had a full colonoscopy at age 50 that it did not need to be repeated. I also read some research that if a person had all polyps removed that there was no evidence that their risk was any different than another person that had no polyps (absent any hereditary condition).
I am a survivor because I did get screened and a mass was discovered. Over many years I received yearly colonoscopies where polyps were always found; then came my routine visit where aggressive cancer was found. The adjutant follow-up treatment was only tolerable for four months instead of the desired six. I can assure anybody that the treatment was much more debilitating than any of the exams. There were times I was incapable of any real functioning and became quite dehydrated requiring hours of additional infusions. I can understand why some cancer survivors refuse treatment should a another cancer return. I'm left with kidney damage and a degree of neuropathy in my fingers and toes after the treatments. OTOH, I'm now 12 years out and at 82 maybe being given a few more years to go.
Oct 17, 2022·edited Oct 17, 2022Liked by Adam Cifu, MD
What strikes me about the colonoscopy debate is that we wouldn't be having it if the cost were trivial and the procedure no more cumbersome or arduous than a blood draw. From a population perspective, I suspect that the impact of colonoscopy is rather small and this doesn't require an RCT to show this. Indeed Adam Cifu's figure that you have to colonoscopy 250 patients to detect 1 premalignant polyp or cancer is indicative of that. However, from an individual's perspective, one has to look at things in a different way and assess the pros and cons as related to ones personal circumstances and preferences. For myself, I would opt for a colonoscopy every 5 years and a FOBT every year. Of course, I would far prefer it if the prep required for a colonoscopy was as minimal as for a flex sig. Because lets' face it, the only bad thing about a colonoscopy is the prep which quite frankly is absolutely disgusting. From my perspective, I don't mind the pooping from midnight through 6 am, but just drinking the prep is really really hard and nausea inducing.
The other key issue regarding colonoscopy, and for that matter flex sig, is that the outcomes and pick up rate are going to be very operator dependent. Perhaps this could be improved by continuously recording the colonoscopy and then subjecting it to subsequent AI analysis as well as analysis by an independent examiner. In other words, colonoscopy/flex sig is not equivalent to a blood test that requires minimal/no human intervention to carry out and whose interpretation is entirely straightforward.
"Colonoscopy actually prevents cancer. A precancerous polyp that is removed poses no threat of mutating/growing into a cancer."
How do you know that the precancerous polyp is not just a manifestation of an underlying cancer, in which case its removal may only slightly mitigate the risk for future disease.
What is the rate of conversion of precancerous polyps to cancerous? Do we have any idea? My old dermatologist used to say “the only good mole is a gone mole” and he made a lot of money through sharing that message with his patients. Unfortunately, he missed melanoma on my friend and it was not associated with a mole!
Surely you have seen harms from colonsocopy during your career? I know I have. Perforations requiring surgery. No deaths that I am aware of. but the cost is huge and that is a potential harm if those resources of money and time were spent elewhere. Also, why compare colonoscopy to doing nothing. Isnt the comparison to sigmoidoscopy or FIT test?
My brother-in-law had a perforation from a colonoscopy a year ago. He was very sick, in the hospital for two weeks, at a cost of several hundred thousand dollars. These risks need to be accounted for in the analysis. A minor point: with a risk reduction ratio of 0.31%, isn't the number to screen the inverse: 323?
Related question popped up for me - is there a way to learn if a health system grades their docs on screening compliance? I changed insurance & health systems (from Kaiser to UW) over the past couple of years and the mammogram guidance to me personally in conversation has differed (still "shared decision-making" but I definitely felt persuaded in different directions). Most recently I agreed to the referral but haven't scheduled - and I'm even getting follow up texts, notes in MyChart, calls. Would love to know if part of the "encouragement" to screen is to meet quotas. I have lower than average risk per various assessments.
So, some easy math here.
Per your comment: “ For those of you who like the “number needed to screen.” These numbers equate to a number needed to screen of 263 to prevent one colon cancer. For a patient, there is a 1/263 chance that your colonoscopy will prevent a cancer.”
263 x $3000 average cost/charge = $789000 or put another way, over $$3/4 of a million dollars all burdened on the taxpayer (Medicare/Medicaid) and/or the insurance premium “payer”.
The studies we need are how to reduce the overall cost burden and actually support/protect patient’s quality life years through lower cost, equally effective “screening “ tools/tests/screening algorithms.
Also not considered here are the patient’s costs as well (prep, lost work, general productivity declines for days, family burden, emotional, etc).
We all want perfect health, and allopathic medicine promises to provide the illusion that it’s possible with all the magic elixirs of “modern” medicine.
My bias of course is I’m medically conservative and also look at cost to benefits (maybe too much).
"I am an avowed medical conservative who thinks that a doctor’s role is primarily to treat disease."
I winced at that statement. I don't want a doctor--any doctor--to _primarily_ treat my disease. I want the doctor to primarily seek to understand and fix or improve the underlying cause(s), and only secondarily treat the disease/condition, either in the interim or because the underlying cause isn't treatable. In any case, in addition to standard medical interventions, I want the practitioner to work toward whole-body health with diet, lifestyle, and nutrients - not just with drugs and endless tests.
Unfortunately, education in diet, lifestyle, and nutrients is woefully lacking in medical schools, and most practitioners are not only uneducated in these interventions, but also unsympathetic, even hostile, to patients who research and implement such approaches on their own. I strongly advocate the integrative approach--taking the best of both worlds, and neither one to the exclusion to the other.
Why not do cologard for general screening, then build a case for more invasive procedures if family history and risk factors (smoking, obesity etc) are present? I appreciate the polyp argument but not all polyps become cancerous. It seems that the point of the recent study was that colonoscopy, as a one-size-fits-all approach, is not warranted.
It is evident that your patients trust and respect you, Dr. Cifu, and that is to your credit.
I am curious as to your opinion on Cologuard for younger, low risk patients who are considering postponing or foregoing colonoscopy due to prep/schedule/anesthesia or other concerns, clearly as just a true screening test. Thoughts?
The writer states "I am an avowed medical conservative who thinks that a doctor’s role is primarily to treat disease.[i] Anything that has the potential of turning a healthy person into a patient should be examined in a very bright light." Then why doesn't she and all doctors tell patients to remove meat and refined food from their diet since they are a strong contributors to colon cancer.
As an oncologist, I value this nuanced approach. We should also not forget that a flexible sigmoidoscopy is a reasonable, less costly and convenient option. Earlier studies have supported the likelihood that screening benefits arise from finding left sided colon lesions, which is what a flex sig does.
I am on team Cifu.
The RCT clearly shows we do not fully understand all of the factors impacting overall mortality. The non-significant difference in colon cancer death is particularly telling - how could this be? Is it possible that the procedure accelerates this outcome in a similar fraction of patients as it prevents? To improve either the procedure itself, or overall care, this should study should be viewed as a challenge to find the answer.
Another issue which has not been addressed in this whole debate is how often to screen - I recall a physician I worked with saying that he believed that if a person had a full colonoscopy at age 50 that it did not need to be repeated. I also read some research that if a person had all polyps removed that there was no evidence that their risk was any different than another person that had no polyps (absent any hereditary condition).
I am a survivor because I did get screened and a mass was discovered. Over many years I received yearly colonoscopies where polyps were always found; then came my routine visit where aggressive cancer was found. The adjutant follow-up treatment was only tolerable for four months instead of the desired six. I can assure anybody that the treatment was much more debilitating than any of the exams. There were times I was incapable of any real functioning and became quite dehydrated requiring hours of additional infusions. I can understand why some cancer survivors refuse treatment should a another cancer return. I'm left with kidney damage and a degree of neuropathy in my fingers and toes after the treatments. OTOH, I'm now 12 years out and at 82 maybe being given a few more years to go.
What strikes me about the colonoscopy debate is that we wouldn't be having it if the cost were trivial and the procedure no more cumbersome or arduous than a blood draw. From a population perspective, I suspect that the impact of colonoscopy is rather small and this doesn't require an RCT to show this. Indeed Adam Cifu's figure that you have to colonoscopy 250 patients to detect 1 premalignant polyp or cancer is indicative of that. However, from an individual's perspective, one has to look at things in a different way and assess the pros and cons as related to ones personal circumstances and preferences. For myself, I would opt for a colonoscopy every 5 years and a FOBT every year. Of course, I would far prefer it if the prep required for a colonoscopy was as minimal as for a flex sig. Because lets' face it, the only bad thing about a colonoscopy is the prep which quite frankly is absolutely disgusting. From my perspective, I don't mind the pooping from midnight through 6 am, but just drinking the prep is really really hard and nausea inducing.
The other key issue regarding colonoscopy, and for that matter flex sig, is that the outcomes and pick up rate are going to be very operator dependent. Perhaps this could be improved by continuously recording the colonoscopy and then subjecting it to subsequent AI analysis as well as analysis by an independent examiner. In other words, colonoscopy/flex sig is not equivalent to a blood test that requires minimal/no human intervention to carry out and whose interpretation is entirely straightforward.