This is an excellent discussion on screening. Patients would be well served to understand that early detection of many cancers is not necessarily beneficial and often leads to more harm than good. Prostate cancer screening has always been controversial. I was shocked by this recent study calling into doubt colonoscopies
Thank you - I, too, was surprised by these results, although had I known the study design prior, maybe I would not have been. Hard to show major effects w/ low rates of an intervention. Screening, though… most doctors do have a bit of a Hero complex, myself included, because it is such an ego-stoking experience to help someone with a problem (which is sometimes not that hard to do). The hard part is when patients don’t have a problem - at least not yet - and we still want to help. “Don’t just do something!” is sometimes the best mantra.
Thanks, Buzz. I have none of the risk factors for colon cancer (except age). In the past I have weighed the financial factors ($10k deductible insurance) against the risk factors, and have always opted for the stool testing. I never even considered, and wouldn't have known where to find, statistics that address all cause mortality in this arena. And I never looked forward to having conversations with my friends about this issue:
"Just got my colonoscopy! All clean! How about you?"
"Uhh, I just poop in a bag and drop it off. So far, so good!"
Your skill at teasing out the probability and statistics surrounding healthcare are second to none. If we had had more of this type of guidance at the state and national level over the past few years, this country would be in much better shape than it is now. I try to never base my health decisions on fear, hysteria, or tunnel vision. I don't have that kind of control over what happens in politics. I wish more doctors were able to see the big picture like this when they are advising our politicians.
Brian, thank you, and I want to publicly confirm that you are NOT a shadow account that I run.
Yours,
BC - I mean - BH
PS In 2029, maybe, we’ll see if the annual poop test really is the best approach; it’s just my best guess right now that it will be. And when I think more about that pending Sweden FIT test vs colonoscopy vs usual care study, the confounders on ppl refusing invitations to screen whether scope or stool test should be less problematic; you could probably directly compare via case-matching those who opted for the screening in both groups head-to-head and fairly well trust the results despite the loss of randomization.
Is there another quality of life issue to consider? In my family's experience, death from at least some types of cancer is painful and stressful, emotionally for the family as well as the patient. Even with good palliative care.
It may be hard to balance against the pain an stress of treatment, much less the cost, given the age and condition of the patient, but if it results in a relatively quick death from another common cause, say a heart attack, doesn't that seem better than suffering from cancer for months?
Thank you for this valuable essay. Several reactions: 1. After reading the 2017 report of the CRC Task Force, I learned that Cologuard contains 2 tests, one fhe $15 Fit, the other the DNA test. However, Exact Sciences will not provide any details on the results. An essay by a physician in a medical jnl. detailed his attempt to get exact measures of his test results, as one would get from a blood test at any lab. The FDA has exempted Exact Sciences from this disclosure. 2. A recent study suggested that 5 FIT tests would approximate the accuracy of a colonoscopy (although not providing removal of polyps or tumors). but it did not state a time frame. Do you have some insight on that?
3. A better test is on the way, provided the company can get through the last FDA hurdle: FirstSight is a blood test detecting CRC (made by CellMaxLife). This seems like a vast improvement over either FIT or Cologuard, and your comments on this possibility would be welcome. Again, many thinks for this article.
I had a colonoscopy on July 20, 2022. On July 23 I had emergency surgery due to a perforated colon which was the result of the procedure. I had 12 incles of my large intestines removed. Three months later, I am still suffering from chronic diarrhea, loss of appetite and fatigue. I had none of the indicators for colon cancer but went ahead with the colonoscopy due to my Doctors recommendations and I am very sorry that I did.
Your story is most unfortunate. What's even more unfortunate is that the medical establishment never speaks of this possible outcome, this risk factor, so you are to be commended for speaking out. I've always wondered how many malpractice lawsuits result from these "accidents" by highly-trained professionals. I've never seen any statistics, again because the medical profession doesn't want this information to be available to the patient population.
I understand your skeptisism, however, I was informed of the risk and choose to go ahead anyway. The men and women in the medical profession are, by nature of their job, in a high risk occupation. I feel my Doctor made an honest mistake and he has shown contrition on numerous occasions. Further, I don't want to conribute to the already overburdened and abused medical malpractice industry. I think the incidence of colon perforation is less than 1% and is in fact so small (as the article state) as to be of little consequence. I was extraordinarily unlucky and will never have a colonoscopy again.
I so appreciate your sympathy and compassion and thank you for sharing your thoughts with me.
It wasn't clear from your earlier comment that you were adequately informed of the risks, but rather were just following a medical dr's advice to have the screening. I've observed that they all recommend it for most people, barely ever mentioning the risks that I'm aware of. Did they specifically mention the possibility of perforated colon?
Assuming you did weigh the risks and potential benefits, it's understandable why you went ahead with it.
I've never had a colonoscopy, and now at age 80 don't ever intend to. I see no potential benefits for me personally, and the potential risks at my age. But as long as everyone is free to make his own decision, that's the way it should be.
Jane, I wholeheartedly agree with you. I can see no reason to put yourself through that especially after reading the article. Unless, you have loved ones that are so concerned for you that the lack a colonoscopy causes them major anxiety, then you may want to reconsider. Colonoscopies seems to be one of these medical fads that pop up every now and then It will fade once a new alarming threat comes along.
Thank you again for your thoughts. By the way, I am 72.
Good for you, 72 is a good age ! I remember it well !
Interesting that you consider colonoscopies as a "medical fad". The medical profession is certainly pushing them these days! The cynic in me would say that it's because they've invested large amounts of capital in the equipment and training, and now need to amortize those expenses.
Yes, medical fads do pop up. Being unable to make much sense of this current "trans" stuff with kids and adolescents, which to me is difficult to defend in any circumstances, I have concluded that this drug and surgery treatment is today's version of electro-shock therapy and prefrontal lobotomies that were recommended in the mid-20th century for those with mental problems, before the days of drug treatment that is the norm today.
If I live long enough, I expect to see rejection of these current questionable trans treatments as cruel and unusual punishment in the name of "science" at the time. It's hard to predict what may happen with colonoscopies in years ahead.
Risk of complications is not zero, so one always has to balance that against the benefit of the procedure. And then some people will have a higher level of acceptable risk (both from the screening tests as well as from the actual disease). The other consideration is with regards to who is doing the procedures. Seeing the same person for a colonoscopy every ten years and having that person do a mediocre job is not likely to be of high benefit. But seeing different practitioners of varying skill level more frequently might well catch a cancer the mediocre provider misses. And then sometimes (oftentimes?) diagnoses are made or missed based on sheer dumb luck.
Thanks for a very interesting overview (from someone who just had a colonoscopy with no polyps and recommended next screening in three years (I did have some polyps removed in a prior colonoscopy three years back, so next one probably justified I'd guess). Worst thing about the prep was having to get up at 12 midnight and not much sleep after for an early morning procedure. I really like it that you generally report absolute risk ratios as well as relative as the latter can sometimes give very misleading impressions.
The meme with the colonoscopy scratched out and replaced with “letters to patients” best describes the results of the study. I find it disingenuous of the study authors to claim no benefit from colonoscopy and it raises questions about their objectivity.
Also, Swedish/European diet, racial background and obesity rates are very different from American and so I also question the direct translation to American practice I.e. African Americans get 20% more colon cancers than average. Also, the number of screening colonoscopies performed in this countries is much lower than the US, so skill could play a role.
I have first person proof that colo-rectal screening works.
But that's apocryphal, right?
My MSKCC oncological-surgeon told me that annual colonoscopies would unquestionably identify life threatening polyps/tumors without any real risk of perforations or other harm, but they just aren't done.
Bonus points for using my new favorite word, “apocryphal.”
Your onc surgeon is almost certainly right, and it’s a great example of how to frame any cancer screening conversation - annual, or even every 2-3 yr colonoscopy on every American over 45 would probably bring the colorectal cancer death rate down near zero. However, when those colonically-blessed people had a heart attack (or colonoscopy perforation!), they would die in their homes since all the hospital systems would have collapsed along with the American health care system due to the expense!
This is an excellent discussion on screening. Patients would be well served to understand that early detection of many cancers is not necessarily beneficial and often leads to more harm than good. Prostate cancer screening has always been controversial. I was shocked by this recent study calling into doubt colonoscopies
Thank you - I, too, was surprised by these results, although had I known the study design prior, maybe I would not have been. Hard to show major effects w/ low rates of an intervention. Screening, though… most doctors do have a bit of a Hero complex, myself included, because it is such an ego-stoking experience to help someone with a problem (which is sometimes not that hard to do). The hard part is when patients don’t have a problem - at least not yet - and we still want to help. “Don’t just do something!” is sometimes the best mantra.
Thanks, Buzz. I have none of the risk factors for colon cancer (except age). In the past I have weighed the financial factors ($10k deductible insurance) against the risk factors, and have always opted for the stool testing. I never even considered, and wouldn't have known where to find, statistics that address all cause mortality in this arena. And I never looked forward to having conversations with my friends about this issue:
"Just got my colonoscopy! All clean! How about you?"
"Uhh, I just poop in a bag and drop it off. So far, so good!"
Your skill at teasing out the probability and statistics surrounding healthcare are second to none. If we had had more of this type of guidance at the state and national level over the past few years, this country would be in much better shape than it is now. I try to never base my health decisions on fear, hysteria, or tunnel vision. I don't have that kind of control over what happens in politics. I wish more doctors were able to see the big picture like this when they are advising our politicians.
Brian, thank you, and I want to publicly confirm that you are NOT a shadow account that I run.
Yours,
BC - I mean - BH
PS In 2029, maybe, we’ll see if the annual poop test really is the best approach; it’s just my best guess right now that it will be. And when I think more about that pending Sweden FIT test vs colonoscopy vs usual care study, the confounders on ppl refusing invitations to screen whether scope or stool test should be less problematic; you could probably directly compare via case-matching those who opted for the screening in both groups head-to-head and fairly well trust the results despite the loss of randomization.
If anyone needs more direct confirmation that I am not a shadow account, give me their address and I will send them a stool sample for DNA testing.
Is there another quality of life issue to consider? In my family's experience, death from at least some types of cancer is painful and stressful, emotionally for the family as well as the patient. Even with good palliative care.
It may be hard to balance against the pain an stress of treatment, much less the cost, given the age and condition of the patient, but if it results in a relatively quick death from another common cause, say a heart attack, doesn't that seem better than suffering from cancer for months?
Thank you for this valuable essay. Several reactions: 1. After reading the 2017 report of the CRC Task Force, I learned that Cologuard contains 2 tests, one fhe $15 Fit, the other the DNA test. However, Exact Sciences will not provide any details on the results. An essay by a physician in a medical jnl. detailed his attempt to get exact measures of his test results, as one would get from a blood test at any lab. The FDA has exempted Exact Sciences from this disclosure. 2. A recent study suggested that 5 FIT tests would approximate the accuracy of a colonoscopy (although not providing removal of polyps or tumors). but it did not state a time frame. Do you have some insight on that?
3. A better test is on the way, provided the company can get through the last FDA hurdle: FirstSight is a blood test detecting CRC (made by CellMaxLife). This seems like a vast improvement over either FIT or Cologuard, and your comments on this possibility would be welcome. Again, many thinks for this article.
I had a colonoscopy on July 20, 2022. On July 23 I had emergency surgery due to a perforated colon which was the result of the procedure. I had 12 incles of my large intestines removed. Three months later, I am still suffering from chronic diarrhea, loss of appetite and fatigue. I had none of the indicators for colon cancer but went ahead with the colonoscopy due to my Doctors recommendations and I am very sorry that I did.
Your story is most unfortunate. What's even more unfortunate is that the medical establishment never speaks of this possible outcome, this risk factor, so you are to be commended for speaking out. I've always wondered how many malpractice lawsuits result from these "accidents" by highly-trained professionals. I've never seen any statistics, again because the medical profession doesn't want this information to be available to the patient population.
I understand your skeptisism, however, I was informed of the risk and choose to go ahead anyway. The men and women in the medical profession are, by nature of their job, in a high risk occupation. I feel my Doctor made an honest mistake and he has shown contrition on numerous occasions. Further, I don't want to conribute to the already overburdened and abused medical malpractice industry. I think the incidence of colon perforation is less than 1% and is in fact so small (as the article state) as to be of little consequence. I was extraordinarily unlucky and will never have a colonoscopy again.
I so appreciate your sympathy and compassion and thank you for sharing your thoughts with me.
It wasn't clear from your earlier comment that you were adequately informed of the risks, but rather were just following a medical dr's advice to have the screening. I've observed that they all recommend it for most people, barely ever mentioning the risks that I'm aware of. Did they specifically mention the possibility of perforated colon?
Assuming you did weigh the risks and potential benefits, it's understandable why you went ahead with it.
I've never had a colonoscopy, and now at age 80 don't ever intend to. I see no potential benefits for me personally, and the potential risks at my age. But as long as everyone is free to make his own decision, that's the way it should be.
Jane, I wholeheartedly agree with you. I can see no reason to put yourself through that especially after reading the article. Unless, you have loved ones that are so concerned for you that the lack a colonoscopy causes them major anxiety, then you may want to reconsider. Colonoscopies seems to be one of these medical fads that pop up every now and then It will fade once a new alarming threat comes along.
Thank you again for your thoughts. By the way, I am 72.
Good for you, 72 is a good age ! I remember it well !
Interesting that you consider colonoscopies as a "medical fad". The medical profession is certainly pushing them these days! The cynic in me would say that it's because they've invested large amounts of capital in the equipment and training, and now need to amortize those expenses.
Yes, medical fads do pop up. Being unable to make much sense of this current "trans" stuff with kids and adolescents, which to me is difficult to defend in any circumstances, I have concluded that this drug and surgery treatment is today's version of electro-shock therapy and prefrontal lobotomies that were recommended in the mid-20th century for those with mental problems, before the days of drug treatment that is the norm today.
If I live long enough, I expect to see rejection of these current questionable trans treatments as cruel and unusual punishment in the name of "science" at the time. It's hard to predict what may happen with colonoscopies in years ahead.
Where was your colonoscopy done?
I'd rather not say.
Risk of complications is not zero, so one always has to balance that against the benefit of the procedure. And then some people will have a higher level of acceptable risk (both from the screening tests as well as from the actual disease). The other consideration is with regards to who is doing the procedures. Seeing the same person for a colonoscopy every ten years and having that person do a mediocre job is not likely to be of high benefit. But seeing different practitioners of varying skill level more frequently might well catch a cancer the mediocre provider misses. And then sometimes (oftentimes?) diagnoses are made or missed based on sheer dumb luck.
Thanks for a very interesting overview (from someone who just had a colonoscopy with no polyps and recommended next screening in three years (I did have some polyps removed in a prior colonoscopy three years back, so next one probably justified I'd guess). Worst thing about the prep was having to get up at 12 midnight and not much sleep after for an early morning procedure. I really like it that you generally report absolute risk ratios as well as relative as the latter can sometimes give very misleading impressions.
I’m the 1%, aspiration pneumonia and 2 nights in the hospital after my last (and I mean last) colonoscopy. I’d rather give birth without drugs again.
The meme with the colonoscopy scratched out and replaced with “letters to patients” best describes the results of the study. I find it disingenuous of the study authors to claim no benefit from colonoscopy and it raises questions about their objectivity.
Also, Swedish/European diet, racial background and obesity rates are very different from American and so I also question the direct translation to American practice I.e. African Americans get 20% more colon cancers than average. Also, the number of screening colonoscopies performed in this countries is much lower than the US, so skill could play a role.
I have first person proof that colo-rectal screening works.
But that's apocryphal, right?
My MSKCC oncological-surgeon told me that annual colonoscopies would unquestionably identify life threatening polyps/tumors without any real risk of perforations or other harm, but they just aren't done.
Why not?
Bonus points for using my new favorite word, “apocryphal.”
Your onc surgeon is almost certainly right, and it’s a great example of how to frame any cancer screening conversation - annual, or even every 2-3 yr colonoscopy on every American over 45 would probably bring the colorectal cancer death rate down near zero. However, when those colonically-blessed people had a heart attack (or colonoscopy perforation!), they would die in their homes since all the hospital systems would have collapsed along with the American health care system due to the expense!