Ask almost anyone after their first colonoscopy, and they’ll tell you, “The procedure was nothing, but the prep was awful.”

Now patients are reporting that combining MiraLAX®, an over-the-counter laxative, with 2 quarts of Gatorade tastes better and is easier to take than the standard 4-quart Golytely colonoscopy preparation. In a randomized clinical trial , almost 100 percent said they would repeat it again, compared to 1 out of 4 who wouldn’t take GoLYTELY® in the future.

In addition, doctors found no differences in how thoroughly the two preps clean the colon.

Splitting the dose between the night before the colonoscopy and the morning of the procedure did improve colon cleansing. But there was no difference in cleansing between split-dose GoLYTELY and split-dose MiraLAX with Gatorade.

Although the combination of MiraLAX and Gatorade is being used to clean the colon before colonoscopy by community gastroenterologists, there hasn’t been evidence that it was safe and effective. Gastroenterologists at the VA Healthcare System in Long Beach, California and at the University of California Irvine developed a randomized clinical trial to compare the MiraLAX prep with traditional  GoLYTELY.

They also compared bowel cleansing quality between giving all of the dose the night before colonoscopy to splitting the dose between the evening before and the morning of the exam.

Results:

• There was no difference in bowel cleansing between the GoLYTELY and the MiraLAX/Gatorade preps.
• There was a significant difference in bowel cleansing when either prep was given in a split dose. Split doses were better.
• On a questionnaire, patients reported better taste and tolerability for the MiraLAX prep.
• 96.8 percent of patients said they would be willing to repeat the MiraLAX prep compared to 75 percent of the GoLYTELY patients.
• There were no significant changes in electrolytes before and after the prep between MiraLAX and GoLYTELY or in single-dose or split doses.

GoLYTELY is a powdered form of polyethylene glycol (PEG-ES) and electrolytes. It is combined with about a gallon of water to draw fluid into the colon to flush out feces.

MiraLAX is also powdered PEG, but doesn’t contain electrolytes. It needs to be combined with two quarts of Gatorade to replace the electrolytes lost in watery diarrhea during the prep process.

Jason B Samarasena MD and his colleagues concluded,

Split-dosed MiraLAX/Gatorade was an effective, safe, and tolerable option for bowel preparation before colonoscopy in the low-risk patients in this study. MiraLAX/Gatorade appears to be more tolerable than Golytely as a bowel cleansing regimen and was the preferred agent by the patients in this study.

What This Means for Patients

Ask your gastroenterologist about combining MiraLAX with Gatorade as a preparation for colonoscopy.

Splitting the prep in two doses: one the evening before your test and the other half the morning before the exam will improve colon cleansing. A clean colon is critical to an accurate exam.

Source: Samarasena et al, The American Journal of Gastroenterology, advance online publication May 8, 2012.

When patients  were offered a choice of colorectal cancer screening with either FOBT or colonoscopy, they were significantly more likely to complete that screening than when their doctors recommended only FOBT or only colonoscopy.

Nearly 1000 racially and ethnically diverse patients in urban primary care practices were randomly assigned to get colorectal cancer screening via:

• Fecal occult blood testing (FOBT)
• Colonoscopy, or
• Their choice of either FOBT or colonoscopy.

Overall, 58 percent were screened within the next year. 

• 67 percent of those offered an FOBT home test finished screening.
• 38 percent of those who got a colonoscopy recommendation actually had the exam.
• 69 percent of patients who had a choice were screened.

Non-whites were more likely to complete FOBT, while whites accepted colonoscopy more often. Latinos and Asians were more likely to complete screening than African Americans

John M. Inadomi, MD and his team concluded,

The common practice of universally recommending colonoscopy may reduce adherence to CRC screening, especially among racial/ethnic minorities. Significant variation in overall and strategy-specific adherence exists between racial/ethnic groups; however, this may be a proxy for health beliefs and/or language. These results suggest that patient preferences should be considered when making CRC screening recommendations.

SOURCE: Inadomi et al, Archives of Internal Medicine, Volume 172, Number 7, April 9, 2012.

How soon should average risk people get another colorectal cancer screening after they have a normal colonoscopy?

No sooner than 10 years, the American Gastroenterological Association recommends as part of the Choosing Wisely campaign.

The AGA’s list of Five Things Physicians and Patients Should Question includes:

1. Use the lowest possible effective dose of acid reducing medicines to treat gastroesophageal reflux disease (GERD).
2. After a negative, quality colonoscopy, don’t repeat colorectal cancer screening by any method for 10 years.
3. After removing 1 or 2 small (less than 1 centimeter) adenomatous polyps without signs of cellular change (dysplasia), don’t repeat the colonoscopy for at least 5 years.
4. After two endoscopies without dysplasia, people with Barrett’s esophagus shouldn’t have another upper endoscopy for at least 3 years.
5. Patients with abdominal pain shouldn’t have a repeat CT scan unless there are major changes in symptoms or clinical findings.

AGA’s list is based on current published recommendations for the time between colonoscopy and endoscopy in people with low risks for cancer.

The Choosing Wisely campaign wants doctors and patients to talk together about tests and treatments that are supported by evidence, don’t duplicate other tests or procedures, are free from harm, and are truly necessary.

Ask your doctor, “Do I really need this test?” and “Do I need it now?”

Seniors’ access to a screening colonoscopy is at risk and YOU can help!

We need you to continue to add your voice and urge your Representative to support H.R. 4120! Simply submit an Action Alert.

H.R. 4120, the Removing Barriers to Colorectal Cancer Screening Act of 2012, will fix a regulation that requires Medicare beneficiaries to pay coinsurance when their screening colonoscopy involves the removal of a polyp. The current policy can cost patients $100 to $300 and serve as a deterrent to screening.

We need cosponsors for this legislation if it is to pass into law & YOU can help!

Representative Charlie Dent

Legislation was introduced in Congress today that will correct an oversight to the Affordable Care Act (ACA) that requires Medicare beneficiaries to pay coinsurance when their screening colonoscopy also involves the removal of a polyp or cancer. When a screening colonoscopy turns therapeutic, the cost to the Medicare patient is significant – $100 to $300 – and it could serve as a deterrent to screening.

The legislation, Removing Barriers to Colorectal Cancer Screening Act of 2012 (H.R. 4120), was introduced by Rep. Charlie Dent of Pennsylvania.

The ACA waived the coinsurance and deductible for covered preventive services that have an “A” or “B” rating from the U.S. Preventive Services Task Force (USPSTF), effective 2011. Colonoscopy, sigmoidoscopy, and fecal occult blood testing (FOBT) all have “A” ratings for adults aged 50 to 75. Unfortunately, the ACA did not waive Medicare beneficiary coinsurance when a colonoscopy turns therapeutic; an oversight that requires legislative correction.

“Fight Colorectal Cancer applauds Rep. Dent for introducing this legislation,” stated Carlea Bauman, Fight Colorectal Cancer’s President. “It is appropriate that this bill is introduced today, the first day of Colorectal Cancer Awareness Month. It is our belief that closing this gap in Medicare benefits will help save lives by keeping colonoscopies affordable and accessible for seniors.”

The median age for diagnosis of colorectal cancer is 71, and the risk for getting the disease increases with age.

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.

When bowel preps are not good, doctors may miss almost half of adenomas (polyps) during colonoscopy.  Worse, they may miss nearly 1 in 3 large adenomas, the most worrisome kind.

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.

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.

Digestive Disease Week  2011 Update

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.

Know someone who needs to be screened for colorectal cancer?

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.