Dr. William I. Wolff

Dr. William Wolff died on August 20 at his home Manhattan.  He was 94.

In the mid 1960′s Dr. Wolff, working with his colleague Dr. Hiromi Shinya at Beth Israel Medical Center in New York, began studying how fiber optics and a long, soft, flexible tube might make it possible to see inside the entire length of the colon.  Together they developed  the first colonoscope.

In 1969, Dr. Shinya invented a wire snare and electrocautery making it possible for the team to remove polyps during a colonoscopy.

By 1973, Dr. Wolff and Dr. Shinya had performed over 2,000 colonoscopies in the Endoscopy Unit at Beth Israel, demonstrating that in skilled hands they could be done safely.  Their use of a wire loop snare and electrocautery made it possible to remove most polyps during the colonoscopy itself and avoid risky abdominal surgery.

Last year more than 1.6 million colonoscopies were done in the United States, preventing tens of thousands of future colon cancers.

In February of 1973, Wolff and Shinya, published Polypectomy via the fiberoptic colonoscope. Removal of neoplasms beyond reach of the sigmoidoscope in the New England Journal of Medicine, a key step forward.

Later that year Dr. Wolff and Dr. Shinya wrote a review of 499 polypectomies, A New Approach to Colonic Polyps, in the Annals of Surgery.  The article has been scanned and is available online from the National Library of Medicine.

Before Wolff and Shinya’s work, colon polyps were identified when there was rectal bleeding or, in rare cases, when the colon telescoped in on itself and produced an obstruction.  How to manage the polyp was difficult.  Either abdominal surgery to remove it or repeated barium enemas to observe it produced a lot of uncertainty for the doctor and anxiety for the patient.  Both surgery and radiation posed significant risks.

Colonoscopy and polypectomy allowed most polyps to be removed without surgery and fully examined outside the body by a pathologist for signs of cancer.

In the Annals of Surgery article, Wolff and Shinya concluded in part:

1. The fiberoptic colonoscope renders all parts of the colon endoscopically accessible in most patients.

2. Most polyps of the colon can be removed via the colonoscope once the requisite expertise has been realized.

3. Endoscopic polypectomy can be accomplished with a high degree of safety: 499 polyp removals are reported with no mortality and with only two significant complications.

Though the years colonoscopy has helped identify patients who have colorectal cancer, manage patients with ulcerative colitis and Crohn’s disease, and now — critically important — prevent colorectal cancer by finding and removing polyps before they can ever proceed to cancer.

We at Fight Colorectal Cancer are grateful to William Wolff for what his work has meant in saving many lives, and extend our sympathy to his family.

You can read his obituary in the New York Times.

Photograph of Dr. Wolff appeared in the New York Times.

The bad news is that bowel prep may be suboptimal in as many of one in four patients.

Because of the danger of missing an adenoma after poor bowel prep, some doctors will repeat the colonoscopy, particularly if they found at least one adenoma during the first exam.  

Doctors at Columbia University Medical Center reviewed all colonoscopies done there from 2006 to 2008, as well as colonoscopies that were repeated within three years.

Of nearly 13,000 colonoscopies, over 3,000 had suboptimal preparation, either fair or poor. Five hundred of those were repeated during the three year follow-up. In the 216 with good preparation for the second exam, 196 adenomas were found in all, 83 only on the second test, an adenoma miss rate of 42%. The miss rate for advanced adenomas was 27%.

For colonoscopies that were repeated within a year, the miss rate for all adenomas was 35% and for advanced adenomas 35%.

Although only a fraction of patients with poor preps had their exams repeated, the additional polyps which were probably missed on the first test were a serious problem.

Dr. Benjamin Lebwohl, who led the study, said,

Our findings of a miss rate of 42 percent for all adenomas and 27 percent for advanced adenomas suggest that suboptimal bowel preparation has a substantial harmful impact on the effectiveness of colonoscopy, and follow-up examination within one year should be considered. Because neoplastic findings on the initial colonoscopy were associated with a greater miss rate, a repeat examination within one year is indicated when an adenoma is found during a colonoscopy with suboptimal bowel preparation

SOURCE: Lebwohl et al., GIE:Gastroenterology, Volume 73, Issue 6,Pages 1207-1214, June 2011

What This Means for Patients.

Following the directions for getting ready for a colonoscopy is very important.

Be sure that

• You keep to diet recommendations including clear liquids the day before your test.
• You understand the laxative plan that will be used to clean your colon and have the prep on hand the day before your exam.
• You drink plenty of clear liquids during your bowel prep.
• You call your doctor right away if your can’t finish the prep because of nausea, vomiting, pain, or any other reason. A different regimen may be prescribed that you can finish.

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.

Although many studies show that men have more adenomas (pre-cancerous polyps) than women, there is no difference in rates of colorectal cancer between men and women.

Could this be because women have polyps that are harder to detect during screening and so aren’t removed in time to prevent cancer?

That was the question that Dr. Joseph Anderson at the University of Connecticut asked.

In 600 consecutive colonoscopies, Dr. Anderson counted the number of polyps overall, as well as those that were flat and those that were both flat and found in the upper part of the colon (proximal) since both flat and proximal polyps are harder to find.  He used a high definition colonoscope to uncover even the most difficult polyps.

He did find more polyps in men — 79 in the 248 men in the study.  There were 71 in 352 women.

• But the women were much more likely to have flat adenomas:  41 of 71 or 57.7 percent.
• Men had 29/79 flat polyps or 39.7 percent.

In addition,

• Almost half (46.5 percent) of women’s polyps were both flat and located in the proximal colon.
• For men, about 1 in 4 polyps (25.3 percent) were the hard to detect flat, proximal adenomas.

Women were almost four times as likely to have a more serious advanced flat, proximal adenoma as men.  19.1  percent of the advanced male polyps were flat and proximal compared to 48 percent of the female ones.

Watch Dr. Anderson describe his research and his results.

SOURCE:  Anderson and Soriano, Digestive Disease Week 2011, Poster Su1538, Larger Proportion of Significant Adenomas Present As Flat and Proximal in Women As Compared to Men: A Prospective Screening Study Using a High Definition Colonoscope.

Send a gentle e-reminder with a card from the American Society for Gastrointestinal Endoscopy.

You can add your own message and Help Catch a Killer.

Other information about colorectal cancer, screening, and colonoscopy, including videos, is available from ASGE on the Screen4ColonCancer web site.

The computer model looked at 100,000 average risk people and compared screening methods results for

• number of colorectal cancer cases
• number of colorectal cancer deaths
• cost of screening and treating colorectal cancer for each screened person

Compared to not screening at all, annual FIT  could save 3 out of 4 deaths from colorectal cancer. For every 100,000 people between 50 and 75, nearly 3,500 people wouldn’t get colorectal cancer, and over 1,300 wouldn’t die.

Not only did FIT screening save the most lives, it was the most cost effective.  It saved about $70 (Canadian) in screening and cancer treatment expenses for each person screened, better than any other method.

FIT vs Colonoscopy

Steven Heitman,of the University of Calgary in Alberta and and his team found

• If no one was screened at all, there would be 4,857 cases of colon or rectal cancer and 1,782 deaths over the lifetime of every 100,000 people in North America.
• Annual testing with FIT reduced cases of colorectal cancer to 1,393 and deaths to 457.
• Colonoscopy done every ten years, with follow-up exams every 3 to 5 years when polyps were found, would reduce cases to 1,825 and deaths to 624.

While FIT was more effective than colonoscopy, it needed to be done every year, while colonoscopy screening is recommended every ten years.  The researchers  wrote,

Although it may seem counterintuitive that screening with FIT could be even more effective than colonoscopy, this is due to the more frequent screening interval with FIT.

The computer assumed that patients would adhere to a program of annual testing with follow-up colonoscopy for positive testing 63 percent of the time.  When adherence fell below 40 percent, colonoscopy became a better option.

Healthcare Costs of Screening and Cancer Treatment

In considering health care costs, the research team included the cost of screening itself, follow-up colonoscopy when required, treating bleeding or perforation complications of colonoscopy or CT colonography, and the cost of recommended surgery and chemotherapy for each stage of cancer.  They also included expenses for time and travel for patients and caregivers.  All costs were reported in 2008 Canadian dollars.

All methods included in the model were considered to be done at the recommended intervals, with appropriate follow-up.  .

Per person screened, the cost of screening and recommended cancer treatment, including biologics for stage IV cancer:

• FIT –$1,833
• No screening — $1,901
• High sensitivity FOBT — $2,084
• Colonoscopy — $2,100
• Low sensitivity FOBT — $2,192
• Flexible sigmoidoscopy — $2,263
• CT colonography– $2,409
• Fecal DNA test (2nd standard) — $2,491
• Fecal DNA (first standard) — $2,720

FIT vs Other Screening Methods

A fecal immunchemical test with mid-level sensitivity was more effective than any other screening method overall.  A higher sensitivity FIT reduced cancers and cancer deaths, but cost more.  A low sensitivity test, with only one sample, was less effective overall — costing more and reducing fewer cases and deaths.

In conclusion, Steven J. Heitman and colleagues at the University of Calgary in Alberta, wrote,

CRC screening with FIT reduces the risk of CRC and CRC-related deaths, and lowers health care costs in comparison to no screening and to other existing screening strategies. Health policy decision makers should consider prioritizing funding for CRC screening using FIT.

Although FIT proved the best at preventing new cancers and cancer deaths, all the screening methods studied were better than no screening at all.

Colorectal cancer screening saves lives!

The American Cancer Society has an excellent review of the current screening guidelines with detailed descriptions of each of the screening methods that were modeled.

SOURCE:  Heitman et al., PLoS Medicine, November 23, 2010.  An Open Access article from the Public Library of Medicine.

What Does This Mean for Patients?

This study offers more information about effective ways of screening for colorectal cancer.

Although you may have considered colonoscopy the “gold standard”,  this research demonstrates that for a large group of people, annual FIT testing actually prevents more cases of cancer and saves more lives.

If the risks of colonoscopy screening concern you, choosing FIT might be a choice for you.  If you do you need to be sure:

• You are willing to do the test every year.
• You realize that a positive test needs colonoscopy follow-up and you are willing to do that.
• Your doctor explains the sensitivity of the different FIT tests and you are given one that has mid to high level sensitivity.
• You get clear instructions for completing the test at home and mailing it back.
• You are an average risk person with no family or personal risks for colorectal cancer.

FIT might also be an affordable choice for people without insurance — although if positive, colonoscopy is necessary.

FIT is a different fecal test than the more commonly used FOBT — fecal occult blood test.  In the computer model, FOBT screening prevented the fewest cancers and saved the fewest lives except for the earlier version of fecal DNA testing.  Be sure that the test you are getting is a fecal immunochemical test.

Image courtesy of SONY Pictures TV

Did Dr. Oz scare you today?

The chances of your colonoscopy resulting in the made-for-TV near-death experience that Dr. Mehmet Oz detailed in a six-part video series on his show and website are highly unlikely. See, Dr. Oz didn’t have a near-death experience, and his colonoscopy story is very common. So can we cut it out with the hysterics, Dr. Oz? You’re scaring people.

As the president of an advocacy organization that fights colorectal cancer, you’d assume that I’d jump on the bandwagon of breathless exultation about how Dr. Oz cheated death with his recent colonoscopy, when doctors found an adenomatous polyp and removed it. Although many colonoscopies result in the discovery and removal of adenomas (like the one Dr. Oz had), 90 percent of them never become cancer.

Even though it’s a big scary word, an adenoma is just a growth in the colon, and most are benign. As in, not malignant. Dr. Oz went in for a routine colonoscopy – he is 50 years old after all – and his doctor found a polyp, something that lots of doctors find when they give 50-year-olds a colonoscopy. Yes, there was a 10 percent chance it could have become cancerous over time, which is why it was removed. The rest of his overblown, overdone, overly-dramatic story, including his heartbreaking anecdote of having to tell his children (sob!) are for the mere benefit of getting people to watch his show.

Unfortunately, a side effect of Dr. Oz’s histrionics is that he’s taken a common condition and turned it into a death-defying act that will scare the living daylights out of anyone who may be approaching the screening age – or who may have already passed it. (If you’re like Dr. Oz and putting off that colonoscopy you naughty kid, go get screened!)

Don’t get me wrong. I appreciate Dr. Oz raising awareness that everyone over the age of 50 must get screened for colon and rectal cancer, even if they eat well, exercise and don’t smoke. No one is immune to this disease. But just because he had a polyp doesn’t mean that he was destined for cancer. It just means that now that the polyp is out, he definitely will not develop colorectal cancer from it. He does have to continue to be screened for additional polyps every three to five years.

Honestly, what scared us most at Fight Colorectal Cancer is that Dr. Oz thought he could put off getting a colonoscopy because he leads a healthy lifestyle. I guess, in this instance, we can all be thankful he has a show to market. Hopefully his viewers can see through his scare tactics to the benefits of screening.

See also:
Dr. Oz’s despicable adventures in self-promotion [Forbes]

A study of stage I, II, and III colorectal cancer patients in the United States found that only 49 percent had received the recommended colonoscopy.

Currently follow-up guidelines call for a surveillance colonoscopy to look for local cancer recurrence or new polyps or cancers a year after surgery.  If that exam is normal, another colonoscopy is called for three years later and then every five years. 

Researchers talked to 1,400 colorectal cancer survivors in the Cancer Care Outcomes Research and Surveillance (CanCORS) study and examined their medical records.  Patients in the study had been diagnosed with colon or rectal cancer between 2003 and 2005.  They all had surgery for stage I, II, or III colorectal cancer and were alive 14 months later.

CanCORS includes lung and colorectal cancer patients in a collaborative study including four geographic areas across the United States, 15 Veterans Administration sites, and 5 members of the Cancer Research Network, a network of managed care organizations designated by the National Cancer Institute to conduct research on cancer prevention and control.

Patients were more likely to have received a surveillance colonoscopy by 14 months after surgery if they:

• had colon versus rectal cancer.
• were seen by a medical oncologist.
• saw a primary care provider in the year after their cancer diagnosis.
• had stage I versus stage III cancer.
• had no other serious medical conditions.

Rates varied significantly depending on the site where care was received from 37 percent to 57 percent.  It was lowest in managed care organizations.

The study authors considered whether or not there was confusion as to who should order a follow-up colonoscopy.  They wrote,

With the often fragmented care of cancer survivors, it may be unclear who is responsible for ensuring adherence to colonoscopy guidelines. Oncologists, primary care providers, and other providers involved in the care of CRC survivors must communicate with each other about their separate responsibilities for detecting second primary cancers.

They said that it is important to know if colorectal cancer survivors are receiving a survivorship plan, as recommended by the Institute of Medicine, whether they understand it, and whether they are sharing it with their primary care providers.

In conclusion, Talya Salz and the study team wrote,

Despite guidelines, more than half of CRC survivors did not receive surveillance colonoscopy within 14 months of surgery, with substantial variation by site of care. The association of primary care visits and adjuvant chemotherapy use suggests that access to care following surgery affects cancer surveillance.

SOURCE: Salz et al., BMC Health Services Research, Volume 10, September 1, 2010.

What This Means for Patients

A colonoscopy a year after surgery is important for stage I, II, and III colon and rectal cancer patients. It can detect a local recurrence at the site of the surgery and, perhaps, a new polyp at other places within the colon.  People who have had one colorectal cancer are at higher risk for another one.

Post cancer surgery surveillance guidelines call for a colonoscopy at 1 year, and — if normal — 3 years later and then at 5 year intervals.

If polyps are found or if the patient has Lynch syndrome, more frequent exams are necessary.

If, for some reason, the entire colon wasn’t examined with a colonoscopy before surgery, a colonoscopy to clear all polyps should be done 3 to 6 months after surgery.  This might happen if there was an obstruction in the colon and the scope couldn’t reach beyond it.

Make sure that your doctors are aware of the need for colonoscopies after your colorectal cancer surgery and that you get prompt referrals for them.  Ask for a written survivorship plan when you finish treatment, whether that is after surgery or chemotherapy.

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.