Some People Getting Colonoscopy Screening Too Often

After a normal colonoscopy when no polyps are found, guidelines call for a repeat test in 10 years.

However, almost half of Medicare patients with a negative colonoscopy got another exam within 7 years, and for one in four there was no clear evidence that they needed one.

Because colonoscopies have real risks and are expensive, over-testing can be both dangerous and costly. Given limited numbers of physicians who do colonoscopies, unecessary procedures add to long waiting lists for screening and for necessary follow-up exams.

Although Medicare regulations call for reimbursement only after 10 years in cases where the first procedure didn’t find a problem, payments are being made for earlier exams.  In fact, Medicare denied payment for only 2 percent of colonoscopies for which there was no clear indication of need.

Researchers at the University of Texas in Galveston reviewed a representative sample of Medicare claims for a  colonoscopy between 2001 and 2003.  Since they were looking for average risk patients who had a negative screening colonoscopy, they filtered out any tests that included removing a polyp or a biopsy or other procedure done during the exam.  They also removed any colonoscopies that included a diagnosis such as bleeding or pain and any that were done for patients who had a Medicare claim in the previous 3 months that included a diagnosis or symptoms of colorectal disease that might have indicated need for a  diagnostic colonoscopy.

In their sample of 5% of the Medicare population:

  • 236,145 Medicare patients 66 and older had a colonoscopy in 2001-2003.
  • 114,468 had an negative exam with no polyps removed, no biopsies or other procedure.
  • 24,071 had a negative screening colonoscopy after all possible medical reasons for doing the test were eliminated.

The research team then looked for repeated colonoscopies within 5 and 7 years of the first test.  Again they eliminated any exams for which a diagnosis or other Medicare claims indicated a good reason to repeat the test.  If they couldn’t find a reason, they classified the colonoscopy as repeated with no clear indication.

In their sample of 24,071 who had a completely negative screening colonoscopy between 2001 and 2003,  8,608 had another colonoscopy within 7 years, and for 3,656 no reason other than routine screening could be found for doing the test.

However, only 86 patients (2 percent) actually had payment denied by Medicare.

Although the US Preventive Services Task Force recommends against routine screening for people between age 75 and 84 and against any screening for those over 85, one third of patients who were 80 or older at their initial negative screening colonoscopy had another exam within 7 years.

The study authors pointed out,

This is of special concern, given the increased potential for complications and decreased benefit of this examination in the very old.

Repeating a colonoscopy early after a negative exam was more likely to occur when:

  • Endoscopist doing the first colonoscopy did more than 1,200 procedures a year.
  • Exam took place in a doctor’s office rather than hospital or ambulatory surgical center.
  • Patients were male.
  • Exam took place in the Middle Atlantic or North Central regions of the United States.
  • Patients had less than a high school education.

For average risk patients without a family history of inherited colorectal cancer, the natural development of cancer from even quite large polyps is slow.  Before the era of colonoscopy, doctors at the Mayo Clinic followed 226 patients who had barium enemas with advanced adenomas (over 1 cm) for 5, 10, and even 20 years.  During that time only 2.5% became cancer at 5 years and 8% at 10 years.  Seven out of ten cancers were found at an early stage before spreading to lymph nodes or distant sites.

After analyzing their results, James Goodwin, MD, and his colleagues at the University of Texas concluded,

A large proportion of Medicare patients who undergo screening colonoscopy do so more frequently than recommended. Current Medicare regulations intending to limit reimbursement for screening colonoscopy to every 10 years would not appear to be effective.

SOURCE:  Goodman et al., Archives of Internal Medicine, online first May 9, 2011.

What This Means for Patients

Although the research was done in Medicare patients over 65, there is no reason to believe that younger patients are not also being screened more often than guidelines call for for.

  • After your screening colonoscopy, be sure that you have a copy of the the results that describe if adenomas (polyps) were found and what their size and description was. If you don’t understand the report, ask your doctor to explain it.
  • Check to see if the recommendation for the next screening exam fits within the guidelines for colorectal cancer screening.  If the return recommendation is sooner that guidelines call for, ask why!

For people at average risk of colorectal cancer, colonoscopy screening is recommended beginning at age 50 and then every 10 years unless adenomas or cancer are found.

The US Preventive Services Task Force says that elderly people between 75 and 84 should not be routinely screened for colorectal cancer and those over 85 should not be screened at all.  If your older relative is getting colonoscopy recommendation that don’t fit the guidelines, ask why. They are at higher risk for complications from the procedure and may well not benefit from screening.

But remember:

  • Symptoms of colorectal cancer at any time – even after a negative screening colonoscopy — and at any age call for diagnostic colonoscopy.
  • People with a family history of colorectal cancer or a personal medical history of cancer, adenomas, or inflammatory bowel disease (ulcerative colitis or Crohn’s disease) are not at average risk. They should follow screening and surveillance programs for increased and high risk, including beginning earlier than 50 and being screened more often.

Comments

  1. MICHELLE says

    I was diagnosed with colorectal cancer at the age of 43. I was at stage III. I am 44 now and just had my last visit with my doctor. He tell me he will see me in one year and then 2 years for a colonoscopy screen. I feel that is to long.

  2. says

    Hello my family member! I want to say that this article is awesome,
    great written and come with approximately all vital infos.
    I would like to look extra posts like this .

  3. Jackie says

    My daughter was having bowel problems age 34. They did a colonoscopy and no cancer showed. Question, whey 8 months later, after we switch Drs, did the new dr find stage 4 Rectal Cancer…? Does Cancer go from Nothing to stage 4 in only 8 months?

  4. Robert says

    My wife had a negative colonoscopy five years ago. History of colon cancer in a large family included a cousin and uncle.

    A FOBT was positive as was a colonoscopy for stage III cnacer.

    The article should give more information as to who is at risk and may need more frequent exams.

  5. Janet says

    I was told the colorectal cancer screening was paid for by medicare so how come I have to pay the hospital

    • Kate Murphy says

      There is an oversight in the Affordable Care Act (ACA) that keeps Medicare for paying for polyp removal during a colonoscopy.

      Screening colonoscopy is a preventive service covered by Medicare without deductibles or co-pays.

      However, once the doctor finds and removes a polyp for biopsy the procedure is no longer “preventive” but becomes “therapeutic” and deductibles and co-pays apply.

      Medicare should continue to pay most of the costs of your colonoscopy with polypectomy BUT you or your supplemental insurance have to cover the rest.

      The hospital can’t bill you for the full cost. Call them and make sure they know you are covered by Medicare and if you have supplemental (Medigap) insurance that the copay should be covered.

      Fight Colorectal Cancer is working on changing the law so that this problem is resolved. You can join us by going to the Fight Colorectal Cancer advocacy site Urge Your Representative to Remove Medicare Barriers to Colorectal Cancer – Support H.R. 4120 and emailing your member of Congress.

      If you are on Medicare, you should NOT be billed for the full cost of a colonoscopy where polyps were removed, but you can be billed for a co-pay. This normally should not exceed $100 to $300.

      to ask your member of Congress to co-sponsor legislation (H.R. 4120)

    • Kate Murphy says

      I suggest that you contact the Fight Colorectal Cancer Answer Line at 1-877-427-2111 and talk over some of the alternatives for colorectal cancer screening and what actually happens during a colonoscopy that might make you fear it less.

      Although colonoscopy every ten years is an excellent screening tool because the entire colon is seen during the exam and any polyps can be removed at the same time, there are other screening methods that also will protect you.

      If you are willing to have your stool to be tested every year with FIT (fecal immunochemical testing), with the possibility that a positive test will need a colonoscopy follow-up, you will be protected. FIT every year is equivalent in preventing deaths from colorectal cancer as colonoscopy every ten years.

      There are other screening alternatives that also might provide protection from colorectal cancer, perhaps not as strong as colonoscopy but as colonoscopy pioneer Sidney Winawer, MD himself said, “The best test is the one that gets done.”

      So, avoiding screening because you are afraid of colonoscopy isn’t necessary. There are alternatives, and there are also ways to calm your fears by understanding what will happen during the process.

  6. Gene says

    My last colonoscopy was done in 2007 with a clean bill of health. Dr recomends that the last in final one in 2017. I am 75 What is your opinion.

    • Kate Murphy says

      Recommendations from the US Preventive Services Task Force are not to do routine colonoscopies after 75 and not to do them at all after 85. The American College of Physicians recommends stopping screening at age 75 and not screening anyone with fewer than 10 years to live.

      In 2017 you’ll be 80, if my numbers are right. At that time, a discussion with your doctor would be in order about your overall health conditions and whether the risk of a colonoscopy outweighs any potential risk of colorectal cancer. Colonoscopy can be dangerous in the elderly, with the potential of the scope making a hole in the colon or bleeding. In addition, older people have more risk of dehydration or side effects from a harsh prep or problems with sedation.

      And, our fingers are crossed here for an easier screening method in the next five years, perhaps even a sensitive blood test.

      I am not a doctor, but right now my feeling is that you should not worry right now about a test five years from now.

  7. Phil Waigand says

    I am a stage 2 rectal cancer survivor. I can’t stress the importance
    of having a colonoscopy exam. My first follow up colonoscopy after
    cancer treatment showed one begnin polyp. Happily, my second follow up
    colonoscopy was negative. My insurance is inadequate and it has
    been very costly for me, but I am cancer free right now, too.

  8. says

    I feel for Mike (above) $180 is a lot to shell out for the test but the cost of not doing it may be much higher. I feel lucky to live in the UK where the NHS takes care of this for you. There is even a free programme of FOB testing for over 50’s. A shame Mr Obama watered down his health reforms

  9. Kate Murphy says

    It is important to realize that there is a difference between screening colonoscopy for patients without symptoms or abnormal tests and diagnostic colonoscopy for people who have symptoms of colorectal cancer or have had a positive stool test (FOBT, FIT).

    Insurance should cover diagnostic colonoscopy , although there may be a co-pay.

    Medicare covers both screening and diagnostic colonoscopies.

  10. Kate Murphy says

    Mike and Frederick,

    The Fight Colorectal Cancer Answer Line Associate will be getting back to both of you with help answering your questions very soon. You have individual situations that need more specific answers.

  11. Mike says

    i did the home stool sample (3 bowel movements ) the Dr detected microscopic blood on ONE sample , now wants me to have colonoscopy , I was going to have one 2 years ago but though I have Blue Cross insurance appearantly they do not cover this procedure , 10 minute office visit cost me $ 180.00 out of pocket then the items for prep were going to cost another 60 , the procedure itself ws going to be over 800 I would just like to know about what the Average is , if I have to pay this out of pocket i cannot afford these prices

  12. Frederick S says

    My father died of colon cancer, as did my sister. When I lived in New Jersey I had a colonoscopy every other year. When I moved to Charlotte the doctors would only do a colonoscopy every 5 years. I didn’t make their 5 year limit. I had stage II colon cancer with surgery in 2009, and in 2011 found, despite follow-up with an oncologist every 90 days, that it had progressed to state IV. If a colonoscopy had been done every other year, this could have been avoided.

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