Advanced adenomas were also reduced significantly.

Scientists at the German Cancer Research Center in Heidelberg compared a group of 553 people who had a negative screening colonoscopy to another group of 2701 who didn’t receive a colonoscopy.

After an average of 11.9 years, there were no colorectal cancers diagnosed in people with a negative colonoscopy compared to 8.4 in the group that weren’t screened.

Advanced adenomas — polyps most likely to become cancerous — were more than 52 percent lower 11 to 15 years later.  Even after 16 years, risk of finding an advanced adenoma was reduced by more than  47 percent.

Statutory health insurance in Germany has offered free screening colonoscopies to people over 55 since 2002.  Since that time over 1.8 million colonoscopy screenings have been done reaching about 40 percent of German women and 30 percent of men.

Hermann Brenner, MD, MPH and his colleagues concluded:

The low risk of CRC and advanced adenomas after a negative colonoscopy supports suggestions that screening intervals be extended to ≥10 years.

SOURCE: Brenner et al., Gastroenterology, Volume 138, Issue 3, Pages 870-876, March 2010.

Evening News anchor and managing editor Katie Couric will be with Smith during the colonoscopy and as he prepares for it the night before.

Gastroenterologist Dr. Mark Pochapin will do the procedure at New York-Presbyterian Hospital/Weill Cornell Medical Center.

Katie Couric had a screening colonoscopy on the air in 2000 which is credited with a 20 percent increase in the number of colonoscopies performed across the United States.  It has been dubbed the “Couric Effect.”

After losing her husband, Jay Monahan, to colon cancer in 1998, Couric has become a leading advocate in the fight against the disease.

Looking back at almost 3,300 colonoscopies performed in community gastroenterology practices in Germany, researchers found a substantial reduction in large polyps or cancers in the left side of the colon and rectum among patients who had had a colonoscopy in the past ten years compared to those who hadn’t had one.

However, in the upper part of the colon, risk for an advanced polyp or cancer was the same whether or not the patient had a previous colonoscopy.

Overall, colonoscopy reduced the risk of a cancer or an advanced adenoma by 50 percent.

Doctors found an advanced colorectal neoplasm, defined as cancer or an advanced adenoma, in about 1 in 10 people who had not had a previous colonoscopy (11.4 percent).  If the person had a colonoscopy in the past ten years, fewer advanced neoplasms were found (6.1 percent), but location in the colon mattered.

The right side of the colon (proximal) was defined as the cecum, ascending colon, and transverse colon.  The left side (distal) was the descending colon, sigmoid colon, and rectum.

If an individual had a colonoscopy in the previous ten years, the risk of finding a large polyp or cancer in the left side was about a third of that of someone who hadn’t had an exam (relative risk 0.33).  However, there was no reduction in the risk of right sided advanced neoplasms.

Risk of cancer itself strongly impacted by previous colonoscopy. Cancer was found in 41 of 2,701 patients who hadn’t had colonoscopy (1.5 percent) compared to only 1 person in the 586 who had one. (0.2 percent).

Hermann Brenner, MD, MPH and his team concluded,

Prevalence of left-sided advanced colorectal neoplasms, but not right-sided advanced neoplasms, was strongly reduced within a 10-year period after colonoscopy, even in the community setting.

In an editorial that accompanied the Brenner study in the Journal of the National Cancer Institute, surgeon Nancy Baxter, MD, MPH and gastroenterologist Linda Rabeneck MD, MPH asked,

Is there an incremental benefit of colonoscopy over flexible sigmoidoscopy for colorectal cancer screening? If so, is the incremental benefit of sufficient magnitude to justify the additional risks and costs of colonoscopy for screening in the population?  Simply put, is the effectiveness of colonoscopy “good enough” for population-based screening? As more observational evidence accumulates, the answer to this question becomes less certain.

Drs. Baxter and Rabeneck point out that there may be biological differences between lesions on the right side of the colon that make it more difficult for colonoscopy to identify and remove them.  They tend to be flatter and may arise through different molecular pathways.

SOURCES: Brenner et al., Journal of the National Cancer Institute, Advanced Access, December 30, 2009.

Baxter and Rabeneck, Journal of the National Cancer Institute, Advanced Access, December 30, 2009 (free complete text).

What Does This Mean for Patients?

This study adds evidence that screening colonoscopy may be mostly effective in preventing cancers on the left side of the colon but may not reduce risk of proximal or right-sided cancer.

This is not a reason to avoid colonoscopy at all. Overall, in the German study it reduced advanced polyps and cancers by 50 percent — a significant improvement.

However, people need to be aware that colonoscopy is not perfect.  Even in people without family history or medical problems like ulcerative colitis or Crohn’s disease, cancer can occur in between screening colonoscopies.  It is critical to be aware of the symptoms of colorectal cancer and get an evaluation of them, including another colonoscopy, if they occur.

It may also strengthen the value of flexible sigmoidoscopy as a screening tool, particularly in situations where colonoscopy is not easily available or affordable.

The American College of Gastroenterology held its Annual Scientific Meeting in San Diego from October 23 – 28, 2009 in San Diego.  Research reported during the meeting included how videorecordings of colonoscopy improved quality tests, the effectiveness of a drug that reduces constipation from opiate drugs, and support for guidelines that call for screening colonoscopy beginning at age 40 for people with a family history of colorectal cancer.

Videos Improve Colonoscopy Performance

When endoscopists knew that their colonoscopies were being recorded on video, their overall performance increased significantly.  They spent more time on each exam and average quality judged on a 1 to 5 scale improved from 2.9 to 3.8.

In a quality improvement program, experienced doctors were not told at first that their colonoscopies were being taped, but digital recordings were made of 8 to 10 tests.  After being told they would be recorded another 10 cases were taped. Both sets of “pre” and “post” awareness tapes were randomly shuffled, reviewed and scored by an expert endoscopist who didn’t know which gastroenterologist did the exam or whether the doctor was aware of not of being recorded.

In reporting the study at the ACG meeting, Douglas Rex, MD, FACG, from Indiana University, concluded,

Videorecording of colonoscopy dramatically changed process quality indicators of colonoscopist behavior toward longer examination time and better technique. Systematic videorecording of colonoscopy may support quality performance of colonoscopy.

ACG Abstract 11, Rex et al. Videorecording Impacts Colonoscopy Performance

Experimental Medicine Helps with Opiate-Induced Constipation

In a randomized, placebo-controlled clinical trial, NKTR-118 increased the number of spontaneous bowel movements in patients with constipation caused by opioid pain medicines.  In addition, the time before the first bowel movement was much shorter than with a placebo. Time before a bowel movement for 25 mg NKTR-118 was 6.6 hours compared to 48.6 hours for placebo and  and 2.9 hours for the 50 mg dose compared to 44.9 with placebo.

NKTR-118 blocks opioid receptors in the gut but does not affect receptors in the central nervous system where opiates work to reduce pain.  There were no opiate withdrawal symptoms or lack of pain relief at any point during NKTR use.

Lynn Webster, MD and colleagues concluded,

In conclusion, the results of this study show that oral NKTR-118 is an effective and safe therapy to normalize GI function in patients with opiate-induced constipation without reversing analgesia.

ACG Abstract 26: Webster et al., Efficacy, Safety and Pharmacokinetics of Oral NKTR-118 in Patients with Opioid-Induced Constipation

Screening Finds Polyps in People from 40 to 49 with a Family History of Colon Cancer

Current ACG guidelines call for screening people with a first-degree relative (parents, brothers, sisters) with colorectal cancer to have screening colonoscopies beginning at age 40.  Doctors at the University of Michigan  reviewed colonoscopies done only for screening in their patients from 40 to 49 who had a first-degree relative with colorectal cancer.  They found adenomatous polyps in 1 in 5, and advanced adenomas in 4 out of 100.

There was no significant difference in either polyps or advanced adenomas depending on whether the relative had been diagnosed with colorectal cancer before or after the age of 60.  However, diabetes did have a significant impact on finding polyps.

Dr. Akshay Gupta and team concluded,

Based upon 21.7% prevalence of adenomas and 3.6% prevalence of advanced adenomas, our data supports current guideline recommendations to begin screening colonoscopy at age 40 among individuals with a family history of colorectal cancer.

ACG Abstract 16A: Gupta et al, Prevalence and Risk Factors for Adenomas in 40-49 Year Old Individuals with a Family History of Colon Cancer

And insurance companies will be required to cover, with no extra charge, routine checkups and preventive care, like mammograms and colonoscopies because there’s no reason we shouldn’t be catching diseases like breast cancer and colon cancer before they get worse. That makes sense, it saves money, and it saves lives.

We applaud the President’s public acknowledgment that colorectal cancer screening saves lives and money.

Screening saves lives by finding cancers early when they are most treatable.  Screening also prevents colorectal cancer by finding and removing precancerous polyps, which keeps them from ever growing into cancer.

Colorectal cancer screening is cost-effective, as evidenced by multiple analyses (see below), which is one reason Medicare began to cover screening in the late 1990’s.

However:

• Unlike preventive screenings like mammograms and pap tests, colorectal cancer screening is not always defined as “preventive care,” so deductibles and co-pays may apply. In other words, even people with insurance may have to pay up to their deductible or pay a part of the cost to get screened for colorectal cancer.
• People without insurance are much less likely to be screened … and with the skyrocketing cost of treatment, Medicare spending for treatment of colorectal cancer is increasing rapidly.

Thanks to hard work by C3 and advocates such as yourself, a national screening program for the un- and under-insured has been proposed in Congress:

• HR 1189:  Colorectal Cancer Prevention, Early Detection, and Treatment Act

Once passed, the program has the potential to save over 30,000 lives and $15 BILLION (through Medicare savings) every year.   It will build on success of the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). The NBCCEDP has provided over 8 million screenings since 1991.  Think of the lives that will be saved once a national colorectal program is in place!

President Obama highlighted screening colonoscopies because they save  lives and money.  If you agree, you can urge your elected officials to take action.

More about screening and colonoscopies

Colorectal cancer screening saves lives. Even the simplest fecal occult blood testing can reduce deaths from colon and rectal cancer by 30 percent.

A colonoscopy examines the entire colon all the way to the cecum at its very beginning.  If a polyp is found, it can be both biopsied and removed. If an early cancer is detected, it can be treated and cured.

Other screening methods search for hidden blood or changed DNA in the stool. If it is found, a follow-up colonoscopy searches for polyps or early cancers. CT colonography, or virtual colonoscopy, uses x-rays to take pictures of the interior of the colon and rectum.  Again if polyps or cancers are uncovered, colonoscopy is used to remove polyps or biopsy potential early cancers.

Colonoscopy screenings also save money. A program in New York City that uses colonoscopy to screen low-income people without insurance found that if Medicare paid for colonoscopy screening for average risk individuals ages 50 to 64, it would save $2 in later treatment expense for every $1 that the screenings and early treatment cost.

Screening Legislation in the US Congress

Currently there are several bills in Congress designed to expand access to colorectal cancer screening, both for the uninsured and for those with insurance.

• HR 1189: Colorectal Cancer Prevention, Early Detection, and Treatment Act of 2009 would establish a national screening program at the Centers for Disease Control and Prevention and give states the option to provide medical assistance for men and women screened and found to have colorectal cancer or colorectal polyps.
• HR 1330: Colorectal Cancer Screening and Detection Coverage Act of 2009 would require that group health plans provide colorectal cancer screening for plan participants who were 50 and over or who were at high risk for colorectal cancer.  Co-pays would be limited to 5 percent of the payment amount and would not be subject to deductible.  In addition, “Nothing in this section shall be construed to require an individual who is a participant or beneficiary to undergo colorectal cancer screening.”
• S 717: 21st Century Cancer ALERT (Access to Life-Saving Early detection, Research and Treatment) Act includes a section on colorectal cancer screening that would provide grants to states and tribal organizations for colorectal cancer screening for people who lack adequate insurance to cover screening.  It would also allow states the option of using Medicaid to cover colorectal cancer treatment cancer found during those screenings.
• S 1511: Supporting ColoRectal Examination and Education Now (SCREEN) Act of 2009 makes a number of changes in existing legislation that would encourage colorectal cancer screening, awareness, and education and reduce out-of-pocket costs.

Some Research Evidence for Screening Cost Effectiveness

• Pignone M, Rich M, Teutsch SM, Berg AO, Lohr KN. Screening for colorectal cancer in adults at average risk: a summary of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine 2002;137(2):132-41.
• Vijan S, Hwang EW, Hofer TP, Hayward RA. Which colon cancer screening test? A comparison of costs, effectiveness, and compliance. Am J Med 2001;111(8):593-601.
• Frazier AL, Colditz GA, Fuchs CS, Kuntz KM. Cost-effectiveness of screening for colorectal cancer in the general population. Journal of the American Medical Association, 2000;284(15):1954-61.

In the news are reports of colon cancer surgery using a tiny incision in the belly button, requirements for KRAS testing before insurance will pay for Erbitux or Vectibix treatment, and information about how stem cells in the intestinal tract become cancer stem cells, driving the development and progression of colorectal cancer.

Research Reports

• In late 2002 colonoscopy became the primary colorectal cancer screening tool in Germany. Since then 1,875,700 men and women have had colonoscopies.  The German Cancer Research Center estimates that the program will have prevented 15,000 colorectal cancers by 2010.  The reduction happened despite a fairly low turnout for screening, 30 percent for men and 40 percent for women between the ages of 55 and 69. Hermann Brenner and his team discuss their study in the European Journal of Cancer, published online March 16, 2009.
• Colon cancers have increased in Chile since mandatory wheat flour fortification with folic acid began in 2000.  Comparing the years 1992-1996 and 2000-2204, colorectal cancer rates for men and women from 45 to 64 were more than two and a half times higher.  For older people 65 to 79, rates almost tripled.  While this suggests a temporal connection between folic acid and colon cancer, there may be other reasons for increased rates including access to health care, increased obesity, and reporting methods.  Similar changes were seen in the United States and Canada after folic acid fortification began in those countries in 1996 and 1997.  Sandra Hirsch’s research is published in the European Journal of Gastroenterology and Hepatology ahead of print, February 2, 2009.
• When their wives with cancer suffered from unrelieved anxiety or pain in the last three months of life, widowers had trouble sleeping as long as four and five years later.  Wives’ anxiety caused almost twice as many men to have trouble falling asleep after the women died, and the men had five times the risk of waking up with anxiety themselves. Their wives’ unrelieved pain doubled the chances that men would have a hard time falling asleep. Researchers emphasized the importance of recognizing and treating cancer pain and anxiety for both patients and their surviving spouses.  Junmei Miao Jonasson reports her findings in the European Journal of Cancer online March 5, 2009.

Other Headlines

• St. Louis University Hospital is doing unique single-incision GI operations that include colectomies for colon cancer. Unlike more common laparoscopic surgery that uses several incisions in the abdomen, single-incision surgery is performed through a small, half-inch opening in the belly button.  Patients have less pain and fewer scars.  The procedure uses flexible scopes and instruments that can move easily within the body, producing views from all angles.  Board-certified colorectal surgeon Dr. Ovunc Bardakcioglu leads the minimally invasive surgical team developing and teaching the techniques.
• Beginning April 1, 2009 UnitedHealthcare insurance programs will require KRAS testing before paying for colorectal cancer treatment with Erbitux® (cetuximab) or Vectibix™ (panitumumab).   Only patients with non-mutated (wild-type) KRAS in their tumor tissue will be considered for coverage.  They recommend, “We encourage physicians to obtain KRAS testing for their colorectal patients as soon as reasonable, and especially prior to starting the drugs cetuximab and panitumumab or earlier if clinically appropriate. “ United has contracts with two national laboratories — Genzyme Genetics and LabCorp — to provide testing.
• Stem cells constantly are repairing and renewing the lining of the colon.  Changes can lead them to becoming cancer stem cells, critical to the development and progression of colorectal cancer.  Scientists at the UK National Stem Cell Network conference say that they know such cells exist, but are not sure exactly which normal cells in the bowel can become cancer stem cells.  Professor Malcolm Allison, the London School of Medicine, told the conference, “Drugs could be targeted to specifically work on cancer stem cells and so provide a more direct approach for treating bowel cancer.” Professor Allison says that he sees patient trials within three years to target and knock out cancer stem cells.  Michelle Roberts has written a story about the conference and colorectal cancer stem cells for BBC News.