In a study of  1,000 ethnically and racially diverse people, the lowest percentage had a colonoscopy when that was the only test offered.  More completed fecal occult blood testing if it was the single choice. Overall 65 percent of the 1,000 patients studied were screened after their doctor recommended testing.

Primary care providers randomly recommended patients be screened for colorectal cancer by:

• Colonoscopy alone
• FOBT alone
• Their choice of colonoscopy or FOBT

In order to make colonoscopy easier, barriers to having the exam were reduced by:

• Reducing or eliminating the patient’s cost for colonoscopy.
• Providing information about the test and preparation for it in the language the patient preferred.
• Providing rides to and from the exam.
• Having an open access system with no more than 2 weeks between test recommendation and the scheduled procedure date.

While two out of three participants in the study had a recommended test:

• 38.4 percent had a colonoscopy when it was the only recommendation.
• 67.1 percent completed an FOBT when only FOBT was recommended.
• 70.0 percent completed screening when they were given a choice between FOBT or colonoscopy.

During a follow-up survey, health beliefs that interfered with having a colonoscopy included

• Fear of test results.
• Fear of cancer treatment.
• Concern that they wouldn’t be able to do the necessary prep.

John M. Inadomi and colleagues in the GI Health Outcomes, Policy and Economics (HOPE) Research Program at the University of California,San Francisco concluded:

Recommendation of colonoscopy alone results in lower adherence to any colorectal cancer screening test compared with recommendation for fecal occult blood test alone or choice of FOBT or colonoscopy.

SOURCE: Inadomi et al., Digestive Disease Week Abstract #124.

In the Netherlands, five nurse endoscopists were trained to do colonoscopies under the supervision of a senior gastroenterologist. Each  had 100 consecutive procedures evaluated for both quality and patient satisfaction.

During the study their exams met international standards for quality, and 95 percent of patients said that, overall, they were satisfied with their experience.

Before the study began, the nurse endoscopists (NE) had already completed a median of 550 procedures, ranging from 260 to 2000 colonoscopies.  Each NE then had her next 100 consecutive exams compared to standards for quality colonoscopy.

In addition, 3 out of 4 patients completed a questionnaire about their experience.

Colonoscopies were performed with conscious sedation.  Two out of five (39 percent) were done for screening or surveillance; the remaining (61 percent) because of symptoms.

• The cecum was reached in 92 percent of cases.
• Average time to reach the cecum was 15 minutes.
• Average withdrawal time was 10 minutes.
• Polyps were found in 1 out of 4 cases (24.8 percent)
• About a third of the time (31 percent) the nurse endoscopists asked for help during removal of a polyp from the supervising gastroenterologist.
• There was one complication, a perforation, in the 500 exams.

In the questionnaires, patients reported:

• Overall, 95 percent were satisfied with their experience.
• 67 percent said they had no pain, 27 percent had mild to moderate pain, 6 percent had substantial pain.
• 99 percent were satisfied with NE communicative skills and 95 percent with their technical skills.
• 71 percent had no preference for NE or physician, 15 percent would prefer a doctor, and 13 percent would prefer a nurse endoscopist.

Concluding, Paul G. van Putten and the Netherlands team said,

Nurse endoscopists perform colonoscopies according to the international recognized quality standards, with high patient satisfaction.

SOURCE:  van Putten et al., Digestive Disease Week 2010 Abstract 683e.

A recent study by the German HNPCC Consortium confirmed the effectiveness of annual colonoscopies to find colorectal cancers at a curable stage.  Regular colonoscopies found early cancers more often than did patient symptoms.

Current recommendations are for surveillance colonoscopies to begin by age 25, be repeated every 1 to 2 years until age 40, and then annually.

Over 1,100 individuals from families with HNPCC were scheduled for annual colonoscopies, and more than 80 percent were completed in less than 15 months.  Ninety-nine colorectal cancers were found in ninety patients.

Of those cancers:

• 17 (17 percent) were identified by symptoms:  8 before the first baseline colonoscopy, 8 when the time between colonoscopies was more than 15 months, and 1 in an interval between tests less than 15 months.
• 43 were found during follow-up colonoscopies, only 2 of which regionally advanced (stage III)

Tumor stages were significantly lower among those whose cancers were found by colonoscopy compared to those identified after patients experienced symptoms.

The researchers divided the study patients into three groups:

• Those with an identified inherited genetic mutation for one of the Lynch mismatch repair genes (MUT group)
• Those without a mutation but with microsatellite instability (MSI group)
• Those with a strong family history that met the Amsterdam criteria but did not have MSI (MSS group)

By the age of 60, the mutation and MSI group combined had a 23 percent risk of getting colorectal cancer.  However, risk for the MSS group was only 1.8 percent.

Patients who had an adenomatous polyp removed during the first colonoscopy had a risk of another polyp that was two and a half times as great as those without that first polyp.  Their risk of subsequent colorectal cancer was almost four times as high.

The Amsterdam II criteria is used to detect families at risk for Lynch-related mutations. Each of the following criteria must be fulfilled:

• 3 or more relatives with an associated cancer (colorectal cancer, or cancer of the endometrium, small intestine, ureter or renal pelvis)
• 2 or more successive generations affected
• 1 or more relatives diagnosed before the age of 50 years
• 1 should be a first-degree relative of the other two (first degree relatives are parents, siblings, or children)
• Familial adenomatous polyposis (FAP) should be excluded in cases of colorectal carcinoma

However, genetic testing is necessary to confirm a mutation.

Christoph Engel and his colleagues in the German HNPCC Consortium concluded,

Annual colonoscopic surveillance is recommended for individuals with HNPCC. Less intense surveillance might be appropriate for MSS families.

SOURCE: Engel et al., Clinical Gastroenterology and Hepatology, Volume 8, Number 2, pages 174-182, February 2010.

You can watch Harry and Katie Couric the day before the test discuss the prep and talk about saving lives by finding polyps. This morning, Katie is in the procedure room with Harry and the medical staff.

Dr. Mark Pochapin demonstrates how the colonoscope works to view the colon, snare polyps if they are found, and remove them.

As Dr. Pochapin withdraws the scope, Harry is awake but comfortable, talking and asking questions.  Dr. Pochapin explains what he is seeing on the video monitor in Harry’s colon.

Afterwards, Harry said, “Piece of cake!  You have a tremendous peace of mind.”

Katie says, “Do it for the people you love.”

Click on Peter's face to hear the song.

Listen to folk singer Peter Yarrow, of Peter, Paul & Mary, sing the Colonoscopy Song.

Yarrow and CBS teamed up to deliver the message that getting a regular colonoscopy saves lives.

Although they “found a polyp hiding, they caught it just in time.”

Colon cancer is one of the few cancers we can prevent successfully with colonoscopy, better than breast cancer or any other cancer with the exception of cervical cancer.

It takes usually about 5-10 years to develop colon cancer, which gives us a great window of opportunity to screen. We know that usually we see polyps first, which can develop into cancer, but that normally takes years. With screening we can see polyps and remove them before they develop into cancer.

Because of this prolonged development, the recommendation have been a baseline colonoscopy at age 50 and then every 5-10 years, but if any polyps are seen repeat colonoscopy in a year except if the polyps are hyperplastic.

Yes, we can prevent colon cancer. There is no discussion that we can.

The dilemma we have is that we still see many patients in their twenties, thirties, and forties with metastatic disease who have some symptoms but are told by their physician it is upset stomach and it can’t be colon cancer because they are too young.

We need to take these symptoms seriously! Any ongoing abdominal discomfort which is not explained should include a colonoscopy as a diagnostic tool even in a young patient.

It is also critical to know that any family history, ANY, will increase your risk and particularly if the family member was diagnosed at a young age. Screening should start about 10 years younger than the family member with cancer.

It is also important to know if there is a genetic predisposition, that colonoscopies need to be done yearly, because in these patients colon cancer can develop much faster and it is possible to see cancer within a year. This syndrome is called HNPCC, hereditary non- polyposis colon cancer. As you probably noticed these patients usually have no polyps but flat lesions which are much more difficult to see on colonoscopy. It is critical to have an experienced gastroenterologist who takes his time to evaluate the colon. It has been shown that up to 20% of the lesions in the right side of the colon (the furthest away from the anus) are easily overseen if you rush in and out.

It is also important that the location of the tumor also is important for symptoms. When the tumor is on the right side, patients have some change in bowel movement habits, some abdominal discomfort, and a feeling like an upset stomach. If the tumor is on the left side, symptoms are more typical including like diarrhea, blood in the stool, and pain with bowel movements.

Please make sure you talk to your family and friends about doing a colonoscopy.

Yes we can prevent this disease.

Over 110,000 Ontario residents had complete negative colonoscopies between 1992 and 1997, almost all done in a hospital (86 percent).  In the 15 year follow-up time through 2006, 1,596 patients developed colorectal cancer.

Although the number of colonoscopies performed by an individual doctor didn’t make a difference in the risk of getting colon or rectal cancer, the physician’s specialization did.  Exams performed by gastroenterologists led to significantly fewer diagnoses of colorectal cancer during the follow-up period than tests done by other doctors, including general surgeons, internist, or family physicians.

Among patients who had their colonoscopies done in private offices, specialization didn’t make a difference in colorectal cancer development after a negative test.

Linda Rabeneck, MD, MPH, of the University of Toronto who led the study said,

The overall incidence of colorectal cancer is reduced for at least 10 years following a negative colonoscopy, compared with the general population. However, colorectal cancers do occur in individuals following a negative colonoscopy. For this reason, having extensive formal training matters, especially when procedures are more challenging to perform. We found that among those physicians who perform colonoscopy in the hospital setting, gastroenterologists are more proficient at colonoscopy than other physicians, including general surgeons. This may reflect the considerable formal training in endoscopy that forms part of gastroenterology core training requirements in the U.S. and Canada.

SOURCE:  Rabeneck et al., Clinical Gastroenterology and Hepatology, online November 2, 2009.

Meeting for two days in Washington in February, a National Institutes of Health State-of-the-Science conference considered what is known– and not known– about why people choose or avoid screening, how to improve screening quality, and what the healthcare capacity is to deliver colorectal cancer screening to the US population.

At the end of the meeting, the panel released a consensus statement with their recommendations for enhancing the use and quality of colorectal cancer screening.

While the panel found that colorectal cancer screening rates were increasing, they still remain too low.  Rates moved from 20 to 30 percent of eligible people in 1997 to 55 percent in 2008, leaving millions of the population unscreened by any method.

To close the gap in screening, the panel identified the following priorities:

• Eliminate financial barriers to colorectal cancer screening and appropriate follow up.
• Widely implement interventions that have proven effective at increasing colorectal cancer screening, including patient reminder systems and one-on-one interactions with providers, educators, or navigators.
• Conduct research to assess the effectiveness of tailoring programs to match the characteristics and preferences of target population groups to increase colorectal cancer screening.
• Implement systems to ensure appropriate follow-up of positive colorectal cancer screening results.
• Develop systems to assure high quality of colorectal cancer screening programs.
• Conduct studies to determine the comparative effectiveness of the various colorectal cancer screening methods in usual practice settings.

In addition to underuse of screening, the panel found situations of overuse:  colonoscopies performed more often than guidelines recommend or patients with serious illness or limited life expectancy being screened without possible benefit.

They also identified misuse of screening when FOBT screening was done in an office setting rather using the recommended home tests.

The most important patient factors in getting screened, the panel discovered, were having insurance and having a usual source of medical care.  Higher income and socioeconomic levels also contributed to being screened.  Although there were lower rates of screening for African Americans and Hispanics, these disparities almost disappeared when insurance and socioeconomic factors were considered.

A recommendation from a physician was the only physician-related factor found that improved screening.  Practices that had electronic medical record reminder systems, staff who could facilitate follow-up arrangements, and patient navigators were the most successful in getting their patients screened.

Two healthcare systems had high screening rates.  Kaiser Permanente achieved a 75 percent screening rate for their Medicare patients, and the Veterans Administration system screens 75 percent of their eligible patients.  Both systems mail FOBT kits directly to patients, use focused reminders, and carefully follow-up all positive tests with colonoscopies.

The panel was concerned about capacity for colonoscopies, particularly for following up positive FOBT results.  They wrote:

Because it is unlikely that current capacity is sufficient for strategies other than universal FOBT screening, expansion of endoscopic capacity may be needed. A first step may be to examine the feasibility of increasing productivity or efficiency of existing facilities. Expanding high-quality endoscopy training to more providers, including nonphysicians, may also be warranted. Such expansion would require careful consideration of quality and patient satisfaction. Also needed is evaluation of the role of incentives, disincentives, and third-party payment policies for performing endoscopy.

In conclusion, the State-of-the-Science Panel wrote,

The panel found that despite substantial progress toward higher colorectal cancer screening rates nationally, screening rates fall short of desirable levels. Targeted initiatives to improve screening rates and reduce disparities in underscreened communities and population subgroups could further reduce colorectal cancer morbidity and mortality. This could be achieved by utilizing the full range of screening options and evidence-based interventions for increasing screening rates. With additional investments in quality monitoring, Americans could be assured that all screening achieves high rates of cancer prevention and early detection.

• Hormone replacement therapy reduces risk of colon cancer.
• Smoking before age 30 increases chances that colon cancer will recur.
• Low CEA levels improve both survival and disease-free survival for stage II colon cancer.
• Most patients want videos of their colonoscopies and are willing to pay for them.

Use of hormone replacement therapy reduces colon cancer

Women in a study of California teachers who were taking hormone replacement therapy (HRT) after menopause had a 36 percent reduced risk of colon cancer over ten years than women who weren’t on HRT at the beginning of the study.  Risk reduction was even greater for women with a first-degree relative who had colon cancer.  Their risk fell 55 percent.

Over 57,000 women were part of the study, about 60 percent of them on HRT at the study start.  Over the next ten years, 444 got colon cancer.

Despite the reduction in colon cancer in the study, doctors caution women about using HRT because of raised risks for breast cancer, heart attack, stroke, and blood clots.  Advice is to use the lowest dose for the shortest time to offset severe menopausal symptoms.

Katherine DeLellis Henderson, PhD, reports the study results in the February 15, 2010 issue of the American Journal of Epidemiology.

Early smoking history reduces disease-free survival after colon cancer

Patients with stage III colon cancer who had a smoking history of 12 or more pack years before they were 30 had almost a 40 percent increased risk of having their cancer return within three years compared to patients who had never smoked.

Among the 1,045 study participants, 46 percent had never smoked, 44 percent were past smokers, and 10 percent were currently smoking.

Disease-free survival three years after treatment was about 18 percent greater for people who had never smoked than for past smokers.

The results, based on questionnaires filled out by patients in the CALGB 80893 adjuvant chemotherapy trial, were published by Nadine Jackson McCleary, MD, MPH,and her colleagues in Cancer, February 15, 2010. They wrote,

Total tobacco usage early in life may be an important, independent prognostic factor of cancer recurrences and mortality in patients with stage III colon cancer.

CEA levels before surgery important for stage II prognosis

Patients whose CEA (carcinoembryonic antigen) blood levels before surgery were low — below 5 ng/ml — had significantly better overall and disease free survival than those whose CEA’s were 5 or higher.  For those with low CEA, overall survival at five years was 81.7 percent compared to 69.9 percent for high CEA.  Disease-free survival was 82.4 percent for low CEA and 70.6 percent for CEA that was 5 ng/ml or higher.

However, CEA levels only made a difference in stage II patients.  There was no significance for stage I or III.

Writing in the Journal of Surgical Oncology, Korean surgeon Jung Wook Huh, MD and colleagues concluded,

Preoperative serum CEA is a reliable predictor of recurrence and survival after curative surgery in patients with colon cancer, particularly in those classified as having stage II disease.

Patients want videos of their colonoscopies

Eight out of ten patients having colonoscopies said that they would like to have a video recording of their colonoscopy, and more than 6 of 10 (63 percent) were willing to pay for it.  After reading a brief paragraph explaining missed lesions during colonoscopy, over half (54 percent) were more interested in a video and none were less interested.

Meghana Raghavendra surveyed 248 outpatients at the Indiana University School of Medicine and reported the results in the World Journal of Gastroenterology, in an early online article January 28, 2010.

There is no doubt that colonoscopies can prevent colon cancer almost 100%.

We have learned over the last couple of years that the experience of the gastroenterologist is critical in identifying suspicious lesions. We have learned that lesions which are on the right side of the colon (farthest away from the anus) can be missed, particularly if they are not growths like polyps but flat lesions.

The key of the success of colonoscopies is how clean the colon is, since any remaining stool can mask small lesions.

Overall, colonoscopy is a very safe procedure, but as with any medical procedure, complications can occur. Studies have estimated the overall risk of complications for routine colonoscopy to be extremely low, at approximately 0.35 percent.

During colonoscopies where a polyp is removed (a polypectomy), the risk of complications is higher, although still very uncommon, at about 2.3 percent. In contrast, the lifetime risk for developing colon cancer is about 6 percent.

Complications during a colonoscopy can include perforation, bleeding, postpolypectomy syndrome, reaction to anesthetic, and infection. Complications during the prep for a colonoscopy are uncommon, but can occur, particularly in elderly patients, or in those with congestive heart failure.

We are particular worried about perforation, which is a tear or a hole in the gut.  The risk of perforation is very low. A perforation can be caused by taking a biopsy from a thin point in the colon wall or when air introduced into the colon during the test to evaluate the intestinal lining better. We have seen that patients who have diverticula or diverticulitis may be at higher risk.

In recent years patients who are being treated for colon cancer with Avastin may be also at higher risk. Therefore, we are particularly careful in patients who receive Avastin. Usually we wait until treatment is completed or wait at least six weeks after the last Avastin dose or in patients with diverticulitis.

We also know that bleeding can occur after colonoscopies  in about 1 out of every 1,000 colonoscopy procedures. The bleeding may be treated during the test, but in most instances, bleeding will resolve on its own. When a polyp is removed, there is a 30 to 50% chance that bleeding will occur anywhere from two to seven days after the colonoscopy. This type of bleeding may also resolve on its own, but may require treatment if it is severe.

If you experience any unusual pain after the procedure or you have ongoing bleeding please contact your physician.