Every year more than 70,000 women are diagnosed with colorectal cancer.   Many of those women see a gynecologist for an annual check-up.  In fact, the gynecologist may be their primary health care provider with a unique opportunity to help women decide on colorectal cancer screening.

A new Committee Opinion from the American College of Obstetricians and Gynecologists says that while colonoscopy is the preferred method for screening, women should also hear about other options.  The Committee Opinion stresses:

Women should be screened using the method that they are most comfortable with and most likely to complete.

The Committee Opinion encourages tests that detect both polyps and early colorectal cancers, with colonoscopy as the recommended option because it visualizes the entire colon, including the right side.  Those tests include colonoscopy, flexible sigmoidoscopy, double contrast barium enema, and CT-colonography (virtual colonoscopy).

However, women should also know about tests that primarily detect early cancers included fecal occult blood testing (FOBT), fecal immunochemical test (FIT), and fecal DNA testing.

Cheryl B. Iglesia, MD, chair of The College’s Committee on Gynecologic Practice, said,

It’s important that ob-gyns be familiar with the various forms of screening exams for colon cancer. No one screening method is best for every woman, so we must lay out the options, help them understand the benefits and drawbacks of each, and let them select the test that best suits them.

SOURCE: Committee Opinion No. 482, Obstetrics and Gynecology, Volume 117, Issue 3, March 2011.

Australia has one of the highest colorectal cancer (CRC) mortality rates in the world. Its current screening program (costing about $29 million a year) provides a one-time immunochemical fecal test (iFOBT) for people aged 50, 55, and 65 years. Program funding expires in mid-2011.

A study funded by the Australian government and the US National Cancer Institute, published in the Feb. 21 Medical Journal of Australia, found that expanding the program to screen all 5 million Australians aged 50 -74 years every two years by iFOBT could end up costing only about $50 million more a year, while saving 300 to 500 lives every year.

“…Expanding the National Bowel Cancer Screening Program is the best investment available to the Australian Government for reducing cancer deaths in the short and long term,” said Professor Ian Olver, CEO of the Cancer Council Australia. He noted that the estimated gross cost, $150 million (including $97 million for follow-up and surveillance colonoscopies), was comparable to existing breast and cervical screening programs. “Yet bowel cancer is killing 1,200 more Australians each year than breast and cervical cancers combined,” Olver said.

Moreover, the expanded screening program would actually end up costing the government only about $80 million a year, study authors estimated, due to fewer CRC cases and lower treatment costs with earlier diagnosis.

Lead author Professor Mike Pignone, University of North Carolina, said “The health system in Australia is well-regarded internationally, so it’s anomalous that such a beneficial program, in terms of both health outcomes and cost-effectiveness, faces an uncertain future.”

This Wednesday and Thursday, March 2nd and 3rd, take five minutes to help us get legislation passed that would create a national screening program in the US. Join the Congressional Butt-in, a phone blitz to Congress!

Sources: Medical Journal of Australia 2011:194 (4) 180-185; Cancer Council of Australia

Olympus and the Colorectal Cancer Coalition are joining forces to encourage at-risk Americans to commit to being screened for colon or rectal cancer. If you are age 50 or older, have family history of colorectal cancer or have other risk factors, you should commit to be screened at FinditFirst.com.

For each screening commitment, Olympus will donate $1 (up to $25,000 total) to the Coalition. In addition to making a commitment to be screened, visitors will also be invited to join Olympus and the Coalition in urging their Members of Congress to support legislation that ensures all Americans access to life-saving colorectal cancer screening.

Make the commitment at FinditFirst.com, get screened and tell your friends and loved ones!

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]

Surprisingly it may not be colonoscopy but fecal occult blood testing (FOBT).

A computer model has found annual home testing with a  fecal occult  blood test, either Hemoccult II® or Hemoccult SENSA®,  is more cost-effective than colonoscopy every 10 years to screen people of average risk for colorectal cancer.

The model compared the number of life years saved under several scenarios of costs and  compliance with annual testing and follow-up colonoscopies after positive guaiac tests.  For the same fixed budget, more people could be screened with an FOBT and more life years saved.

Organized state and federal screening programs are faced with a complex task of choosing the right test that will get the most people screened effectively at the lowest cost.  In addition to the cost of the test, program planners have to consider how many patients will follow up with repeat fecal occult list blood testing every year and how many will actually get a colonoscopy if they have a positive test.

Best case scenario: With 100 percent compliance with screening recommendations and follow-up testing, a budget of $1 million dollars would result in a total of 50.9, 52.8, and 40.9 additional life-years for the population of individuals screened with Hemoccult II, Hemoccult SENSA, and colonoscopy, respectively.

The average lifetime cost per person is $1,399 for Hemoccult II, $1,656 for Hemoccult SENSA, and $2,110 for colonoscopy as the primary screening method.  Costs included colonoscopy follow-up when tests are positive.

In computing costs, a cost of $23 for FOBT and $699 for colonoscopy was used.

Other scenarios:

A program using Hemoccult II, with a screening compliance of 60 percent or higher, will yield more total life-years gained than a program using colonoscopy with 100 percent compliance.  Hemoccult II will perform better than colonoscopy if at least 75 percent of those with positive guaiac-based fecal occult blood tests undergo diagnostic follow-up colonoscopies.

Only at the lowest level of compliance with testing and follow-up  is colonoscopy more effective for broad public screening programs.

Health economist Sujha Subramanian and her team at RTI International concluded,

Although colonoscopy is currently emerging as the most frequently performed colorectal cancer screening test in the United States, in many instances it might not be the optimal choice, especially for programs with fixed budgets. Across a broad population, as opposed to for use in a particular individual, the Hemoccult SENSA test can result in more benefit than colonoscopy. Therefore, colonoscopy should not be automatically considered the appropriate choice.

SOURCE: Subramanian et al.,Health Affairs, published online July 29, 2010.  The entire article is available online.

What Does This Mean for Individuals?

This study was designed to look at public screening programs with fixed budgets, not make recommendations for individuals.

Your screening choice, as an individual, may be different.

Colonoscopy allows both screening and removal of any polyps that are found during the procedure.  Per test, it is more sensitive for cancer and polyps than FOBT, but may not find all polyps. For average risk patients, it only needs to be repeated every 10 years unless polyps are discovered.

FOBT requires careful compliance to an annual screening schedule and faithful follow-up of all positive tests with a colonoscopy.

People with extra risk because of family or personal history of colorectal cancer or polyps or patients with ulcerative colitis or Crohn’s disease need to be screened with colonoscopy and more often.

Discuss the right test for you with your doctor!

One out of three Americans who needs colorectal cancer screening hasn’t gotten it.

There are 22 million men and women in the US who haven’t had a life-saving test than can prevent colorectal cancer.

But the good news is that screening rates are going up.  In 2000, half of people who should have been screened reported a current test.  Now almost two-thirds have colorectal cancer screening up-to-date

The bad news is that screening rates for the uninsured are almost half those for people with insurance. 

According to the Centers for Disease Control, 62.9 percent of US adults from 50 to 75 were current with colorectal cancer screening.  They either had a fecal occult blood test (FOBT) in the past year or a sigmoidoscopy or colonoscopy during the past 10 years.  That’s up from 51.9 percent in 2000.

The figures come from the 2008 Behavioral Risk Factor Surveillance System (BRFSS) survey.  The BRFSS surveyors randomly dial nearly half a million Americans to ask about their health.  In 2008 BRFSS reached over 201,000 adults from age 50 to 75 to ask if they had ever used “a special kit at home to determine whether the stool contains blood (FOBT)” or had a “tube inserted into the rectum to view the colon for signs of cancer or other health problems (sigmoidoscopy or colonoscopy)” and when these tests were last done.

Overall US Screening in 2008

• 14.1 percent said they had an FOBT within the past year.
• 58.5 percent had sigmoidoscopy or colonoscopy sometime in the past 10 years.
• 62.9 percent had either FOBT or an endoscopy and were up-to-date.

However, screening rates weren’t consistent.  Some groups fell substantially below the national 62.9 percent, particularly those with no health insurance, less than a high school education, or limited income.

There was little difference in rates for men or women or for black or whites.

Health Insurance

• Insured — 65.7 percent
• Not insured — 35.6 percent

Age

• 50 to 59 — 53.9 percent
• 60 to 69 — 71.1 percent
• 70 to 75 — 75.8 percent

Race and Ethnicity

• White — 65.9 percent
• Black– 62.0 percent
• Asian/Pacific Islander — 55.5 percent
• American Indian/Alaskan Native — 54.4 percent
• Non-Hispanic — 64.2 percent
• Hispanic — 49.8 percent

Income

• Less than $15,000 — 47.6 percent
• $15,000 to $34,999 — 54.0 percent
• $35,000 to $49,999 — 61.3 percent
• $50,000 to $74,999 — 72.9 percent

Education

• less than high school — 46.1 percent
• high school graduate — 58.1 percent
• some college/technical school — 63.7 percent
• college graduate –70.6 percent

There are also differences in screening rates among the states with 74 percent of people up-to-date  in 3 northeastern states in Maine, Delaware, and Massachusetts. The lowest rates occurred in the central and western regions in Oklahoma (53 percent), Arkansas (53 percent), and Idaho (54 percent).

The CDC estimates that if current trends in health behaviors, screening, and treatment continue, there should be a 36 percent decrease in the rate of colorectal cancer deaths by 2020.

Led by L.C. Richardson, MD, the CDC team concluded,

CRC screening rates continue to increase in the United States. Underscreening persists for certain racial/ethnic groups, lower socioeconomic groups, and the uninsured.

SOURCE:  Richardson et al., Vital Signs: Colorectal Cancer Screening Among Adults Aged 50–75 Years — United States, 2008, CDC Morbidity and Mortality Weekly Report, online July 6, 2010.

Doctors in Europe examined 328 patients who either had colon disease or were suspected of having it with both a capsule colonoscopy and traditional optical colonoscopy.  The capsule contained  tiny video cameras at both ends that transmitted images wirelessly from the upper GI tract and the colon.

Compared to optical colonoscopy the capsule found:

• 64 percent of polyps larger than 5 millimeters (about 1/4 inch)
• 73 percent of advanced adenomas
• 14 of 19 cancers

The PillCam, manufactured by Given Imaging, is about 1 and 1/4 inches long and is swallowed with a sip of water.  Bowel preparation is more extensive for the capsule because it needs some clear liquid to travel through the bowel.  Less than ten percent of patients had mild to moderate side effects from the test, mostly related to bowel prep.  They included abdominal discomfort, nausea and vomiting, and headache.

Andre Van Gossum, MD and the study team concluded,

The use of capsule endoscopy of the colon allows visualization of the colonic mucosa in most patients, but its sensitivity for detecting colonic lesions is low as compared with the use of optical colonoscopy.

In an editorial accompanying the article in the New England Journal of Medicine, Michael Bretthauer, MD, PhD from Oslo University said that the low sensitivity of capsule colonoscopy was a concern.  Because of low sensitivity, the extensive bowel preparation required, and high cost ($1,150) he concluded, “”colon capsule endoscopy cannot be recommended at this time.”

Partial results from another study of capsule colonoscopy, not yet complete, were reported during Digestive Disease Week in early June. Patients in that study were at increased or high risk for colon cancer. Capsule colonoscopy found polyps in 22 percent of patients compared to 21 percent during the optical colonoscopy which followed. Sensitivity for polyps larger than 5 millimeters was 55 percent.

Colon cleansing was a particular issue in this study.  Patients were on a low-residue diet for 3 days before the capsule was swallowed.  They had 3 liters of PEG solution the day before the procedure with a second liter the day of the test.  Additional laxatives were taken during the time the capsule was traveling through their systems.  Despite this bowel prep, adequate bowel cleansing was present in only 55 percent of patients. However, the same bowel cleansing was judged good to excellent for optical colonoscopy in 87 percent.

There were 5 adverse events among the 105 patients, two serious ones including a colon perforation and a cardic problem that might have been related to the bowel prep.

SOURCES: Van Gossum et al., Capsule Endoscopy versus Colonoscopy for the Detection of Polyps and Cancer, New England Journal of Medicine, Volume 361, Number 3, July 16. 2009.

Sacher-Huvelin et al., Wireless Capsule Colonoscopy Compared to Conventional Colonoscopy in Patients At Moderate or Increased Risk for Colorectal Cancer, Digestive Disease Week 2009 Abstract #276.

In the month of March we are working to increase awareness that lives can be saved with screening. and colorectal cancer often can be prevented.

There is no shame in preventing cancer, and there are no reasons not to undergo screening. I have done my colonoscopy myself since I have a family history of colon cancer. It was pretty easy. The worst was the preparation a day before…which, in fact, was my day in Norris clinic. When I can do it, you can.

Regular screening tests can find precancerous polyps so they can be removed before they turn into cancer. We know that screening with colonoscopies can also find colorectal cancer early when treatment can cure the cancer.

Colon cancer is unique because usually it takes 5-10 years to develop. The first step is a polyp, a benign growth that looks almost like a mushroom. However, it takes a long time before some of these polyps can turn into cancer. It is easy to find these polyps and remove them during colonoscopy. Polyps often have no symptoms at all, which means we should not wait for symptoms but undergo screening at age 50 as baseline and repeat it every 3-5 years.

If doctors find polyps, depending on the type, they may repeat the colonoscopy in one year to make sure the don’t grow back fast.

Colorectal cancer may not cause symptoms, especially at first. Colon cancer affects both men and women, therefore there is no excuse for men or women not to be screened. Most insurance plans, including Medicare, help pay for colorectal cancer screening.

For some people colonoscopies are just too threatening. Virtual colonoscopy is being developed. which is a CT scan looking into your colon. So no scope up your behind. However the colon still needs to be clean. and the preparation is the same for colonoscopy. If they find something on the virtual you have to undergo the real one.

The Center of Disease Control (CDC) has asked celebrities such as Jimmy Smits, Diane Keaton and Katie Couric to speak out to raise awareness of this preventable disease. Check out the Screen for Life website.

In March, we at USC invite all our patients for a reception with wine and food and talk about our progress in the clinic and the laboratory. To talk in a causal setting without the white coats or receiving chemotherapy is a pleasant surprise. This has become one of my favorite events.

The program estimates that it has prevented 180 cases of colorectal cancer and 80 deaths.

Primary focus is on the uninsured 50 to 64, but colonoscopies are also offered to high-risk people under 50.  Program participants need to have incomes below 250 percent of poverty.

Centered at the University of Colorado at Denver, the program works with more than 65 community clinics throughout Colorado.  Patient navigators in the clinics locate patients in need of screening, arrange an appointment with a participating doctor for a colonoscopy, and remove barriers to completing the screening.

If cancer is found during screening, the program is able to cover treatment costs not paid by other resources.

On March 5, 2009 the program held its annual meeting followed by a Statewide Dialogue on Colorectal Cancer Screening.

However, if patients are not willing to have a colonoscopy, they support offering:

• Preferably. a cancer prevention test: Either flexible sigmoidoscopy every 5 to 10 years  or CT colonography every 5 years.
• A test primarily for cancer detection: Preferred test is fecal immunohistochemical test for blood (FIT).

They further recommend that African Americans begin testing at 45 rather than 50.

Changes from the 2000 Guidelines include:

• Screening tests are divided into cancer prevention and cancer detection tests.  Cancer prevention tests are preferred over tests that primarily detect colorectal cancer.
• Screening is recommended for African Americans beginning at age 45.
• CT colonography every 5 years replaces double contrast barium enema as the radiology screening alternative when patients decline colonoscopy.
• FIT (fecal immunohistochemical testing) replaces older guaiac-based fecal occult blood testing.  FIT is the preferred cancer detection test.
• Annual Hemoccult SENSA and fecal DNA testing every three years are alternative cancer detection tests.
• A family history of only small tubular adenomas in first-degree relatives (parents, children, siblings) is not considered to increase the risk of colorectal cancer.
• Individuals with a single first-degree relative with colorectal cancer or advanced adenomas diagnosed at age 60 or older can be screened like average risk people.

The Guidelines also include guidelines for screening patients with a family history of colorectal cancer, familial adenomatous polyposis (FAP), and hereditary non-polyposis colon cancer (HNPCC).

Douglas K. Rex M.D. and the team that developed the update summarized their recommendations:

This document is the first update of the American College of Gastroenterology (ACG) colorectal cancer (CRC) screening recommendations since 2000. The CRC screening tests are now grouped into cancer prevention tests and cancer detection tests. Colonoscopy every 10 years, beginning at age 50, remains the preferred CRC screening strategy. It is recognized that colonoscopy is not available in every clinical setting because of economic limitations. It is also realized that not all eligible persons are willing to undergo colonoscopy for screening purposes. In these cases, patients should be offered an alternative CRC prevention test (flexible sigmoidoscopy every 5–10 years, or a computed tomography (CT) colonography every 5 years) or a cancer detection test (fecal immunochemical test for blood, FIT).

SOURCE: Rex et al., American Journal of Gastroenterology, advance online February 24, 2009.