Sunday, January 13, 2013

Is Colonoscopy the Best Colon Cancer Screening Test?

The medical arena, like society at large, is permeated with self-interest. This reality makes me very skeptical that comparative effectiveness research, which I support, will get airborne. In medicine, every heath care reform, new medicine, new medical device or revised medical guideline is at some constituency’s expense.  Recognizing and dismantling conflicts of interests is one of our greatest challenges and threats. 


When I was a gastroenterology fellow over 20 years, our department was active in new technologies to crush and dissolve gallstones and stones that had wandered from the gallbladder into the liver pipes. Millions of dollars of R & D were spent and the procedures were done in specialized centers in the U.S and abroad. The treatments were cumbersome and only modestly effective, but the treatments continued year after year. Then, laparoscopic cholecystectomy arrived, a new operation that could remove gallbladders with much less pain and recovery time. At that moment, the gallstone dissolving business dissolved. As endoscopic techniques improved, gastroenterologists could safely and easily remove stones from the liver pipes, which became the preferred method for accomplishing this objective.  These outcomes served the public good, but this is not always the case. .

New medical developments are often pursued for both marketing and medical reasons. Large medical institutions will spend mightily for the latest high-tech robotic laser shooting burger-flipping tumor ray gun, even if (especially if) the competitor across the street already has one. Here in Cleveland, I suspect we have a mind numbing duplication of medical services in a very tight geographic reason. Since availability correlates with usage, I surmise that we are a model of overtesting and overtreatment. I am not assigning blame. Indeed, I need to be reeducated as much as anyone since we all practice medicine in a culture of excess.

The prism that should be used to view new medical development is if it serves the greater good. Many folks, however, define the greater good to be any outcome that coincides with their own parochial concerns. Conversely, if a particularly group is threatened by a medical advance, then it will be alleged that the greater good will surely suffer.

To a gastroenterologist, 50 is a milestone year. This is the age that we pounce upon you to scour your colon to remove cancers-in-waiting. While we champion this test, and sincerely believe in its worth, it is not ideal. Here are some drawbacks.

  • The pre-colonoscopy cathartic cocktail
  • Anxiety
  • Discomfort (no it’s not always painless)
  • Cost
  • Risk of complications
  • High rate of negative results
  • Loss of a day’s wages or personal enjoyment
  • Need for a driver
What will gastroenterologists' reaction be when a better test threatens to retire our colonoscopes? Will we defend colonoscopy against a simple analysis of a person's stool which is just as effective? Will we claim that the research behind the new development is flawed? Gastroenterologists have successfully prevailed against CAT colonography, a competing test which examines the entire colon for polyps using a CAT scan. We have the edge in this duel since patients who pursue the CAT scan option must still take a vigorous laxative and, if polyps are discovered, they cannot be removed. Colonoscopy’s unrivaled advantage is that it can remove nearly all polyps discovered. It’s one stop shopping.  If radiologists perfect the technique of performing a CAT colonography without any required laxatives, then the scales may tip in their favor. 

The above vignette is not a futuristic hypothetical creation. I suspect that colonoscopy and CAT colonography will be properly forced out during my own career as colon cancer screening techniques. Colonoscopy will still be performed, but only when some kinder and gentler screening test indicates that an individual has a high probability of harboring polyps. It will no longer be wielded in a buckshot fashion.  The number of colonoscopies being performed will be decimated.

When that happens, it will not be good news for the Kirsch family. But, it will be greater good news for everyone else’s family.

9 comments:

Anonymous said...

As well there is the problem that many people who have had colonoscopies decide they dont trust the surgwons any more.
I bled from alleged diverticulitis and after the colonoscopy (third) was told if I bled again I would get my colon cut out.
Luckily for me I worked out that I was bleeding from regular aspirin taking. Stopped that and AOK.

Daniel Weiss MD said...

I believe the government and other insurers which reimburse primarily for procedures and testing are a central problem. The patient is peripheral. Healthcare is shielded from usual market forces. For all else, cars, computers, and other services (including cosmetic surgery) market forces help drive down cost and promote innovation.

Rusty said...

Colon cancer is really common to people who loves to eat burnt meats. Rumors spread that burnt meats contain carcinogens which may cause certain cancers. Is it true?

There are also certain kind of stomach pains which is caused by "Diverticulitis?" I never heard of it until I found this (http://technoflake.info/what-is-the-difference-between-diverticulosis-and-diverticulitis/) blog.

Toni Brayer, MD said...

I think there will be innovations that do replace cumbersome colonoscopy. Perhaps a test strip that detects changes in DNA or cell enzymes. Until that time, colonoscopy will prevail. There is no reason, however for the high cost. It could be performed by trained technicians, assembly line style. The cost for the procedure and the facilities charges are grossly out of line.

Despite all of this, colonoscopy is the only "screening" test that can cure cancer. It is important to have it.

Angina Berryz said...

Hi,
Thanks, for sharing such great post. Colonoscopy is the endoscopic examination of the large bowel and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus.
Thanks,
Colonoscopy

Caro said...

“It is difficult to get a man to understand something, when his salary depends on his not understanding it.”
― Upton Sinclair, I, Candidate for Governor: And How I Got Licked

Carolyn Kay
www.ManyYearsYoung.com

John Lynch said...

I love what you're doing here, Dr. Kirsch, especially since it so comports with my own postings. However, I just had my third colonoscopy and, while acutely sensitive to the self-interests you describe, still find it one of the less controversial screening procedures with a far better risk-to-benefit ratio than most. I wrote about it here - http://bit.ly/UzPb8p

Anonymous said...

Fantastic post, Dr. K!

I TOTALLY agree, and have been telling my colleagues in Clinical Research for years, that, for the reasons of self-interest that you highlight, Comparative Effectiveness Research will never truly see the light of day. No drug company wants risk finding out that the product they've spent upwards of a billion dollars testing in Phase III trials is no better, or even worse, than the standard of care.

Ditto for the physician-scientist who just so happens to be the co-inventor of said drug company's blockbuster-in-the-making.

Policy makers and some enterprising pharma firms may dance around the topic, or even allow a token trial or two between two branded drugs that already have a branded-generic waiting in the wings for the expiration of the patent, but until our medical expenditures are so astronomically ruinous that even members of Congress cannot afford their care, nothing will change.

Bank on it.

Anonymous said...

People might consent to colonoscopy more if it weren't for the horrible misery of the laxative prep. That's really horrible for anyone to go through. I'm an R.N., and I won't do it.

Add this