Colonoscopy every 10 years appears reasonable for low-risk people

Despite the fact that screening colonoscopy is advised for adults ages 50 and older, there is not much scientific data to bolster recommendations for how often to undergo the test. The major medical groups recommend colonoscopy every 10 years for people ages 50 and older who are considered at low risk for colon cancer. In general, people who are at high risk, such as those with previous precancerous lesions, should undergo screening every three years.

A new study based on a mathematical model of incidence of the disease, effectiveness of the test and the costs and complications of testing suggests that the standard recommendations are probably on target.

Researchers from the University of Michigan and Ann Arbor VA Health Services found that screening high-risk people every three years and low-risk people every 10 years is effective in reducing colon cancer cases and deaths, although it costs more than conducting no screening whatsoever. Screening low-risk people every five years is much more costly but only marginally more effective. Screening low-risk people every three years,- which some doctors do to avoid lawsuits arising from "missed" colon cancer, is not only not cost-effective but is potentially harmful due to the increased incidence of complications from the test.

However, the authors said, more research is needed to better clarify who is at high- or low-risk in order to sharpen the guidelines even further.

"There is evidence that we are overusing colonoscopy in low-risk patients and under-using colonoscopy in high-risk patients," the lead author of the study, Dr. Sameer Dev Saini, said in a news release. "We need to focus our efforts on high-risk patients, who have the most to gain from these procedures."

Late last year, changes were recommended to both mammography and Pap smear cancer screening tests. It's quite possible that today's recommendations for colonoscopy will also change at some point. For example, better technology shows that some colon cancers are flat or depressed lesions that may go undetected. As more is learned about the disease and screening technology improves, recommendations for screening will be subject to ongoing debate, Saini said.

The study was released Monday in the journal Gastroenterology.

— Shari Roan

Photo: The flexible colonoscopy tube holds a fiber-optic lens through which a physician can see inside the body. Credit: Robert Durell / Los Angeles Times.

And now, medical images for your weekend browsing pleasure

Remember those oddities we promised -- as in "Booster Shots: Oddities, musings and news from the health world"? The venerable New England Journal of Medicine is here to help.

The journal doesn't call them "oddities," of course. The journal calls them "featured images in clinical medicine," and it offers one up every week.

This week's offering is cutis marmorata in decompression sickness. It's interesting enough, but perhaps not what nonspecialists would consider odd. To most people, mottled-looking skin is mottled-looking skin.

But the Diphylloborthrium latum found during a colonoscopy? Fascinating. Absolutely fascinating. And the video...

-- Tami Dennis

Photo: If these walls could talk...

Credit: Los Angeles Times

Become a fan: Become a fan of our Facebook page and get a steady stream of health- and medical-related news, musings and the occasional oddity.

A kinder, gentler colonoscopy

Preparation for a colonoscopy could soon be substantially easier if research by a Detroit gastroenterologist is confirmed.  Dr. Chetan Pai of the Henry Ford Hospital reported Sunday at the Digestive Diseases Week meeting in New Orleans that it may not be necessary to consume the large amounts of unpleasant liquids now required to prepare for the procedure, which will be a major relief to anyone contemplating it.

Colonoscopies are a highly effective method of both detecting and preventing colorectal cancer. A flexible tube is inserted through the rectum and a miniature television camera is used to view the entire inside of the colon. Polyps, precursors of tumors, can be snipped out when they are found. This procedure is relatively painless because it is typically done under sedation and the patient doesn't feel a thing. An estimated 146,000 cases of colorectal cancer are diagnosed each year in the United States and nearly 50,000 die from it. But early detection can sharply reduce the mortality.

Ah, but getting ready for it is another story. For the procedure to be effective, it is important to clear out all the fecal matter from the intestines. That is done by inducing diarrhea. In the past, that was done with phosphosoda, which was unpleasant to drink, but didn't require more than a couple glassfuls. But doctors found out that phosphosoda was dangerous, so now the laxative of choice is Go Lightly, a solution of polyethylene glycol. Generally, physicians recommend at least a gallon of the solution. But the solution is hard to swallow in adequate quantities, especially for older people. "Even my own family don't want to get colonoscopies" because the preparation is so unpleasant, Pai said.

Anecdotal evidence suggests that the problem can be avoided in part by using lubiprostone, a pill that is normally used to overcome constipation. Pai decided to conduct a clinical trial to see if it worked.

He enrolled 102 patients with an average age of 57 who were scheduled to have a colonoscopy. Half were given lubiprostone--one tablet two days before the procedure and one tablet with each meal the day before the procedure--and half a placebo. All were also given Go Lightly and told to continue drinking it until they achieved a clear bowel movement.

Those who took the lubripristone, sold under the brand name Amitiza, drank significantly less Go Lightly, Pai said. Some were able to consume as little as one 8-ounce cup. Physicians who didn't know which regimen the patients received found that the preparation quality was virtually identical for the two groups and that there was not any difference in the detection of polyps.

The study was funded by Sucampo Pharmaceuticals Inc., which manufactures Amitiza.

-- Thomas H. Maugh II

CBS' Harry Smith undergoes colonoscopy televised live

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It’s been 10 years since Katie Couric had a colonoscopy on national TV. She has been advocating for these potentially life-saving cancer screening exams since her husband, Jay Monahan, died of colorectal cancer in 1998 at the age of 42. Couric’s televised procedure inspired thousands of Americans to get screened – researchers from the University of Michigan documented a 20% increase in the number of colonoscopies performed in the nine months following her broadcast.

On Wednesday morning, CBS' "The Early Show" host Harry Smith had his own colonoscopy televised live from the Jay Monahan Center for Gastrointestinal Health at New York-Presbyterian Hospital. As he put it, his goal was to “demythify” the procedure for the men and women who know they should get the test but are just too squeamish to make it a priority.

During the procedure, a doctor inserts a flexible scope into the rectum that snakes six feet to the beginning of the colon. The scope contains a camera to spot cancerous or precancerous polyps. It can also spray water to rinse the colon, carbon dioxide to blow back the folds of the colon, a special blue light makes polyps easier to see, and a small wire that can cauterize any polyps that look dangerous.

The screening exam is important because colorectal cancer is highly treatable if caught early. As Couric explained from Smith’s bedside – dressed in green scrubs, a white lab coat and wearing a gratuitous stethoscope around her neck – the goal is to remove the polyps before they grow into tumors that spread to the lymph nodes and metastasize throughout the body.

Some other tidbits:

• The exam should last at least six minutes. Any faster and the doctor isn’t being sufficiently thorough.
• Men and women at average risk should get the test once every 10 years starting at age 50. People with an increased risk should start earlier and get the test more often.
• In 2009, 146,970 people were diagnosed with colorectal cancer and 49,920 people died from it.

Smith said the most annoying part of the whole procedure was the bowel prep the day before (which involves many trips to the bathroom). As for the test itself, he said there was “nothing to it,” and the clean bill of health he received gave him “tremendous peace of mind.”

You can view the 19-minute video – which includes many rear-end jokes – by clicking on the link above.

-- Karen Kaplan

Video courtesy of CBS's "The Early Show"

Sure, President Obama can get a virtual colonoscopy, but you ... (And should you?)

Perhaps you read that President Obama recently had a virtual colonoscopy instead of the more traditional kind. And perhaps you're thinking, "Hey, if I have to have a screening of my large intestine, make mine a virtual one too!"

Not so fast.

The National Digestive Diseases Information Clearinghouse makes these key points about virtual colonoscopies: They're not without their own unpleasantness (the colon must still be emptied). They don't always find small polyps. And if they DO find a problem, then you've got to make a date with a long, lighted flexible tube anyway.

Not deterred? Keep this in mind: Medicare and many health insurance plans won't pay for them.

Here's today's story on Obama's first physical exam since he became president.

And, as context, an earlier L.A. Times story on the debate about virtual colonoscopies.  Here's a quick passage: "But there is still no consensus about the effectiveness of the new procedure. Some critics contend it could inflate the nation's skyrocketing healthcare tab because a traditional colonoscopy is required if anything is found in the imaging."

Interesting, no?

Here's a primer on the traditional kind. Truly, they're not so bad.

-- Tami Dennis

Photo: Left, a polyp as seen using virtual colonoscopy software, and on the right, the same polyp as seen with  conventional colonoscopy.

Credit:  Dr. Perry Pickhardt / Associated Press

Panel recommends eliminating financial barriers to colorectal screening

Eliminating financial barriers and providing more direct contact among patients and physicians and providers are the best ways to improve the rate of screening for colorectal cancer, a National Institutes of Health Consensus Conference recommended Thursday after meeting for three days this week in Bethesda, Md. The recommendations are not binding on any group or agency--they simply represent the best advice of experts in the field about what would be the optimum approach to solving the problem.

Colorectal cancer is the second-leading cause of cancer death in the United States and part of the reason for that is limited screening, because the disease is highly curable if caught early. As recently as 1997, only 20% to 30% of the eligible population--primarily those over the age of 50--underwent screening. By 2008, the percentage was up to 55%, but that is still very low compared with screening for other cancers, which can reach 80% to 90%. Experts would like to see the rate get up to at least 80%, and the consensus panel was convened to consider ways to do that.

One way is to have better insurance coverage. High co-pays and lack of insurance cause many people to ignore calls for screening. Some insurance companies, such as Kaiser Permanente, as well as the Veterans Affairs health system, have achieved much higher screening rates by offering better coverage for the testing, and the panel recommended that others follow suit. A national program to provide free screening has begun in 22 states, but it is too soon to see if that is working.

Another problem that may be more difficult to overcome is fear of pain during the procedure itself and disgust at the preparations that are necessary for colonoscopies. The pain is minimal and does not occur if the patient is sedated. It is necessary to clear out the colon before screening, and that requires imbibing large quantities of a foul-tasting liquid to induce diarrhea, and there seems to be little that can be done about that now. Less invasive tests are available, but they are not as accurate and must be repeated more often. And positive results from them require followup with more invasive tests.

"We recognize that some may find colorectal cancer screening tests to be unpleasant and time-consuming," said Dr. Donald Steinwachs of Johns Hopkins University, chairman of the panel. But "we also know that recommended screening strategies reduce colorectal cancer deaths. We need to find ways to encourage more people to get these tests."

The panel also noted that, if the screening rate can be increased, there will be a higher demand for screening facilities and new ones may have to be constructed.

The most common screening methods include:

-- Fecal occult blood tests and immunochemical tests, which look for blood in the feces not visible to the naked eye. It should be repeated every year after age 50.

-- Sigmoidoscopy, an internal examination of the lower part of the large intestine with a small television camera attached to a flexible tube inserted into the anus. It should be repeated every five years.

-- Double-contrast barium enema, an X-ray examination of the intestines following the intake of contrast material. It should be repeated every five years.

-- Colonoscopy, an internal examination of the entire large intestine. It should be repeated every 10 years.

-- Computed tomography colonoscopy, often called a virtual colonoscopy. The colon and rectum are observed with a CT scanner. It should be repeated every five years.

-- Fecal DNA, an examination of feces searching for DNA shed from tumors. It is not clear how often it should be repeated.

More information about colorectal cancer screening is available here.

-- Thomas H. Maugh II

Cancer deaths down, but statistics are sticky

Our hard work to live more healthfully seems to have paid off, with a new annual report showing that cancer death rates have been dropping since the 1990s. The risks are still higher for men than for women, but men showed the greater drop in deaths, falling 10% from 2002 to 2006 as opposed to 7.5% for women.

Consider also that in 2009, more than 713,000 women and 766,000 men are projected to be diagnosed with cancer, lead author Brenda K. Edwards of the National Cancer Institute said in an interview.

Each year, the report takes an in-depth look at one particular type of cancer to draw conclusions about the why, not just the how much, of cancer death rates. This year, the team looked at colorectal cancer. Aside from being the second most deadly cancer threat, it serves as a good model for studying the declining cancer rate.

Researchers found about half of the decline was due to better screening, Edwards said. (Last year, the report singled out the No. 1 killer, lung cancer, and the team was able to point to smoking controls in California for its comparatively better lung cancer rates.) 

Edwards also raised some concerns that overall numbers would mask certain issues – for example, that lung cancer for women is still on the rise, though it’s going up more slowly than before.

The report, published online in Cancer, is a joint effort of the institute, the American Cancer Society, the Centers for Disease Control and Prevention and the North American Assn. of Central Cancer Registries.

David Agus, director of the USC Center for Applied Molecular Medicine, said in an interview that better screening practices, technologies and healthier lifestyles have contributed to the decline, but he also delivered a reality check on the data.

“This is not acceptable. We need to be down like heart disease, stroke, infectious disease, where the rates are down 50%,” Agus noted. “In the cancer world we’re not much better at doing things than we were five decades ago.”

-- Amina Khan

Virtual colonoscopy gets an endorsement

Virtual colonoscopy to screen for colorectal cancer has been in use in clinical trials for several years. Today, however, the technology was recommended for anyone who needs screening colonoscopy. While the test still requires what doctors politely call "bowel preparation," the new technology will be easier, safer and more comfortable for patients, to be sure.

The study endorsing widespread use of virtual colonoscopy is published in this week's New England Journal of Medicine. The largest study to estimate the accuracy of the technology, the research was sponsored by the National Cancer Institute and had 1,256 participants at 15 study sites, including UCLA. The participants underwent a virtual colonoscopy followed by a traditional colonoscopy, usually the same day. The results showed virtual colonoscopy is comparable in accuracy to traditional colonoscopy. Virtual colonoscopy was highly accurate in finding moderate to large polyps, which are unusual growths that could be cancerous or precancerous, and even very small polyps were detected with high sensitivity.

Colorectal cancer is the third most frequently diagnosed cancer in the country and the second leading cause of cancer death in American men and women. Colonoscopy is considered the definitive test for colorectal cancer screening and prevention.

"It is our hope that this less invasive option for screening will lead more people to get screened for colorectal cancer, which would result in fewer deaths," said Dr. Peter Zimmerman, principal investigator for the UCLA study site.

Virtual colonoscopy is performed with computerized tomography -- which is why it is also called CT colonoscopy. A standard colonoscopy uses a long, flexible tube with a camera that is threaded through the colon, but CT produces three-dimensional pictures taken with the CT scanner with only a thin tube inserted in the rectum. The test could greatly benefit the 5% to 10% of people who cannot have complete, regular colonoscopies because they have abdominal lesions or a very twisted colon.

There are some caveats to virtual colonoscopy, say experts from the American Gastroenterological Assn. For one, the test is more accurate in experienced hands. Also, if a polyp is found you still have to undergo a regular colonoscopy to have it removed. Finally, CT scans emit radiation. It's not easy to assess how much radiation people might get from virtual colonoscopy, however, because the exposure varies among the types of machines used, according to the AGA.

For more information on virtual colonoscopy, see the AGA web page entitled "What is CT colonography?"

An accompanying study, also in the New England Journal of Medicine, found that people need not have a colonoscopy any sooner than five years after the last normal scan. Many doctors recommend screening colonoscopy once every 10 years after age 50. But, until this new study, there were no data to support when another exam is warranted after the first normal one. People with symptoms, such as pain or bleeding, would need exams more often, as would anyone who has a family history of colon cancer.

-- Shari Roan

Photo: Computer-generated, 3-D picture taken from a CT colon exam. Credit: AP / Courtesy of Dr. Perry J. Pickhardt, University of Wisconsin Medical School.