Colonoscopies are the gold standard of colorectal cancer screening tools. “They’re important because virtually all colon cancers in our society come through first as benign polyps,” explains my gastroenterologist Dr. Douglas Howell. “Colonoscopy is not colon cancer detection, it’s actually colon cancer prevention. Patients who undergo removal of polyps are essentially then assured they will not develop colon cancer for a number of years. It’s very protective over a long period of time and that makes it a good buy.”
I’m grateful for colonoscopies. I had my first at age 50 and Dr. Howell found and removed a polyp. He recently found two more, which he also removed. It usually takes a long time for colorectal cancer to develop to the point of causing symptoms. I’d rather nip it in the bud—for real.
But even with the cancer prevention success that a colonoscopy offers, plenty of people balk at having to go through the prep and the exam. It’s not fun, that’s true. But think of the potential alternative.
I’ll never forget getting a call in 2014 about John Nappi, who was in the hospital recovering from major surgery. For several months, he had unrelenting diarrhea and a few other symptoms. He never dreamed he might have cancer, but he did. Stage 4 colon cancer that had spread to his lungs.
John contacted me because he wanted to do an interview and urge people to say yes to a colonoscopy. He certainly wished that he had. “I was like every other male,” he told me. “I was afraid of it. Now, I don’t know what I was afraid of. Maybe of what they might find or maybe it’s that most men don’t want to be examined there. I don’t know why we’re afraid. I just kept saying no. All of my other numbers were good. I said, ‘I’m not going to have that problem.’”
Sadly, John died of his cancer in January 2016.
The U.S. Preventive Services Task Force (USPSTF), an independent volunteer panel of national prevention and evidence-based medicine experts, recognizes that a significant portion of the population is just like John. In June 2016, it issued updated guidelines for colorectal cancer screening that gives people several options, including but not limited to a colonoscopy.
“About one-third of eligible adults in the United States have never been screened for colorectal cancer,” the final report stated, “and offering choice in colorectal cancer screening strategies may increase screening uptake. As such, the screening tests are not presented in any preferred or ranked order; rather, the goal is to maximize the total number of persons who are screened because that will have the largest effect on reducing colorectal cancer deaths.”
USPSTF screening options
The guidelines offer six screening options for people aged 50–75. (You can read the entire recommendation statement at uspreventiveservicestaskforce.org)
• gFOBT (guaiac-based fecal occult blood test)
Done annually, this test looks for hidden blood in the stool. No prep is needed, but you have to avoid certain foods or medicines. To do the test, you smear small stool samples on a special card coated with guaiac and mail it to the lab or doctor.
• FIT (fecal immunochemical test)
Annual test that is similar to the gFOBT but looks for hidden blood in a different way, and you don’t have to avoid certain foods or medicines.
• FIT-DNA (multi-targeted stool DNA test)
Done every one to three years. The test checks for hidden blood as well as genetic markers that have been connected to colorectal cancer. You need a prescription from your doctor to get the test kit and provide an entire stool, which you mail to a lab. Cologuard® is currently the only FDA-approved FIT-DNA test.
Direct visualization tests
Done every 10 years as long as no precancerous polyps are found and removed. You have to prep beforehand so that your bowel is completely empty. You may be given a sedative so that you will be comfortable during the procedure, which usually takes about 30 minutes. The doctor inserts a tiny scope with a camera into your rectum and looks at your entire colon. If any polyps are discovered, they can be removed and sent for biopsy.
• Flexible sigmoidoscopy
Done every five years. Colon needs to be completely empty but the doctor only examines the rectum and lower part of the colon. If there are any polyps, they can be removed. If cancerous or precancerous, a colonoscopy will be needed to check the rest of the colon.
• CT or virtual colonoscopy
Done every five years. The prep is the same as a regular colonoscopy, but you might also need to drink some contrast material. Instead of using an internal camera to visualize the colon, pictures are taken outside the body with a CT scan. Air or carbon dioxide is pumped into the bowel so the inside is easier to see. It’s less invasive than a colonoscopy and you don’t need sedation, but if a polyp is detected, you’ll need a colonoscopy to have it removed. Also, the procedure does not seem to be widely available.
Dr. Evan Barnathan is the chief resident for Maine Medical Center’s family medicine residency program and the physician lead for Maine Medical Partners colorectal cancer screening quality improvement workgroup. He agrees wholeheartedly that having options should prompt more people to get screened.
“When people are given the options, not just colonoscopy, they are doubly likely to get screened,” he says. “Patients may say, hey, there are all these tests, which one’s the best? In reality, it’s the one that’s going to get done.”
If you’re not sure what to do, check with your doctor. “A physician’s recommendation increases someone’s likelihood of being screened by 90 percent,” he says. “So just to go in and see your doc and ask and get more information.”
All of the recommended screenings are covered by insurance, says Dr. Barnathan. “As part of the Affordable Care Act, everything that was graded A or B by the USPSTF is covered. The 2016 update provided Grade A evidence that all these services are just as good as the others for colon cancer. So, yes, all these services are covered.”
Because of increased screening and improved treatments, colorectal cancer deaths went down 52 percent from 1970 to 2015. That’s great news, but it is still the second leading cause of cancer deaths among men and women in the United States. This year, it will kill an estimated 50,000 people.
The USPSTF recommends that screening should begin at 50, but younger people should also be aware of any unusual symptoms (see below). Unfortunately, for unknown reasons, colorectal cancer rates are increasing among younger adults.
According to the National Cancer Institute, “researchers predict that by 2030, based on current U.S. trends, colon cancer incidence rates will increase by 90 percent for people aged 20 to 34 years and by 28 percent for people aged 35 to 49 years, whereas they will decrease by 38 percent for people aged 50 to 74 years and by 45 percent for those 75 years or older.
Colon cancer symptoms
• No matter what your age, if you have any of these symptoms be sure to get them checked out:
• A change in bowel habits, such as diarrhea, constipation or narrowing of the stool that lasts for more than a few days
• A feeling that you need to have a bowel movement even after you go
• Rectal bleeding
• Dark stools or blood in the stool
• Cramping or abdominal pain
• Weakness and fatigue
• Unintended weight loss
Whatever you do, don’t procrastinate. You have options. Get screened.
Diane Atwood writes the blog Catching Health with Diane Atwood, which received a Gold Lamplighter Award from the New England Society for Healthcare Communications and a Golden Arrow Award from the Maine Public Relations Council. Find it at catchinghealth.com.