In the United States, a colonoscopy is considered the gold standard for colon cancer screening. The recommendations for screening in average risk individuals aged 50 to 75, according to the United States Preventive Task Force are:
- annual fecal occult blood testing with a sensitive test
- flexible sigmoidoscopy every five years with sensitive fecal occult blood test every three years
- colonoscopy every 10 years
Unlike the United States, Canada does not agree that a colonoscopy is superior to other colon cancer screenings. The Canadian Task Force on Preventive Health Care actually recommends against the use of colonoscopy as a screening method for colon cancer among average risk individuals aged 50 to 74. This recommendation is based upon the absence of randomized controlled trials that show a mortality benefit of screening colonoscopy. Instead, they recommend fecal occult blood testing and flexible sigmoidoscopy (Source: Reuters).
With these differing points of view, how can you know that the screening method you are choosing is the most effective in preventing colon cancer? Are colonoscopies really superior? Let’s ask an expert. StopColonCancerNow.com recently interviewed Paul E. Brown, M.D., of Louisville Endoscopy Center in Kentucky about the importance of colonoscopies for early detection and prevention of colon cancer. Dr. Brown is the Medical Director of Louisville Gastroenterology Associates and specializes in internal medicine and gastroenterology.
From your extensive experience in the field of gastroenterology, are all colon cancer screening methods created equal, or is one method more effective than others?
All colon cancer screening methods are not created equal. The United States Preventive Task Force revised their recommendations for colon screenings in 2001 because physicians were unable to diagnose, at an early stage, a significant number of colon cancers. There were several reasons for this. Fecal occult blood testing is only able to detect the presence of blood in the stool but cannot detect colon cancer. A flexible sigmoidoscopy allowed physicians to inspect only 60 centimeters of the colon, which meant that we could examine the left portion of the colon but the sigmoidoscope could not reach the mid-portion of the colon or the right side of the colon.
The colonoscopy is a superior test because it is not only a method of colon cancer detection, but also a method of colon cancer prevention. When I perform a screening colonoscopy, I am checking for early colon cancer, but I am also looking for polyps. If I find a polyp during an exam, I will remove that polyp because I know that 95 percent or more of colon cancers develop from a polyp. About 30 to 40 percent of my patients undergoing a screening colonoscopy will have a polyp, and I will remove that polyp so that it never has the potential to become a cancerous lesion. Therefore, we can say that colonoscopies are not only diagnostic, but they are also therapeutic.
Since the revision of the guidelines in 2001 that recommend screening colonoscopies every 10 years, what results have we seen in the United States?
We have seen that screening colonoscopies are superior to other screening methods. There are two main reasons for this:
- Colon cancers can be detected very early. There is a 90 percent survival rate when detecting colon cancer at an early stage.
- Resected polyps can never become cancerous lesions, and studies reveal that the higher the polyp detection/removal rate, the lower the colon cancer risk.
In 2010, we began monitoring the decline of colon cancer incidence. In a span of three years, we saw a decline of 4 percent per year. Colonoscopies statistically work! They are an effective mechanism of detection, prevention and reducing the incidence of colon cancer.
Even though we are seeing a decline in the incidence of colon cancer, where do we still need to improve?
Although education and awareness have increased colon cancer screening rates, only 65 percent of adults in the United States are choosing to be screened. A significant percentage of people who are still not opting for colon cancer screening are individuals of low socioeconomic status and the under-insured.
Previously, cost was the greatest obstacle to undergoing a screening. Now, however, all screening colonoscopies are covered at 100 percent under the Affordable Care Act. The federal government recognizes the importance of colonoscopies in colon cancer prevention, and all individuals with Medicare are entitled to a free screening colonoscopy, if they meet eligibility guidelines. Colon cancer is much less expensive to prevent than to treat. The overall cost of treating an individual with colon cancer averages about $250,000 to $300,000, so any money invested in polyp removal could save hundreds of thousands of dollars in the future, as well as preventing human suffering and loss of life.
Can you share some information about your recent trip to Washington D.C. and how that is related to colon cancer prevention?
I belong to a group of independent GI physicians called the Digestive Health Physicians Association. We traveled to Washington D.C. to lobby for the waiving of coinsurance for a screening colonoscopy, when a polyp is removed or a biopsy is performed. We are asking that as long as the necessary actions are occurring within the same clinical procedure as the screening, that it would be fully covered at 100 percent with no deductible and no copay.
Currently, if an individual schedules a screening colonoscopy and a polyp needs to be removed or a biopsy is necessary, the colonoscopy will be coded as diagnostic and the patient is subject to a deductible and copay. We are asking Congress to make an adjustment on the wording of the guideline.
Our bill reads as follows,
"This bill amends title XVIII (Medicare) of the Social Security Act to waive coinsurance for colorectal cancer screening tests (in order to cover 100 percent of their cost under Medicare part B [Supplementary Medical Insurance Benefits for the Aged and Disabled]), regardless of the code billed for a diagnosis as a result of a test, or for the removal of tissue or other procedure furnished in connection with, as a result of, and in the same clinical encounter as the screening test."
There are two separate bills, HR 1220 in the House of Representatives and S 624 in the Senate. We are receiving a great deal of support and are hopeful that our visit created momentum to move this bill forward.
What sets StopColonCancerNow surgery centers apart in the quality of their colonoscopies?
Firstly, the vast majority of physicians at [these] surgery centers are all GI trained physicians. We are gastroenterologists who have undergone stringent training criteria, whereas many surgeons are trained minimally in colonoscopy. We monitor several quality parameters to maintain the highest standards for a colonoscopy:
- What is my adenoma detection rate? This is the percentage of time that at least one adenomatous polyp is detected during a physician’s screening colonoscopies. The national average is 25 percent for men and 15 percent for women. Our percentages at [our] surgery centers are much higher, and range between 25 and 50 percent. Again, the higher the adenoma detection rate, the lower the colon cancer risk.
- How many times do you see the entire colon? This is called the cecal intubation rate and refers to the colonoscope advancing to the farthest point in the colon called the cecum. This should be greater than 95 percent for screening colonoscopies. This assures evaluation of the entire colon.
- What is the withdrawal time? This refers to how quickly the scope is removed from the colon once the colonoscope reaches the cecum. The minimum time should be six minutes because that is when we are inspecting the colon for polyps. Greater than 6-minute withdrawal time correlates with a higher adenoma detection rate.
- What is the quality of the bowel preparation? Although this quality measure relies heavily on the patient following the preparation guidelines, there is a responsibility on the physician to provide adequate literature and comprehensive counseling. We need to fully explain how essential the bowel preparation is for a thorough examination. The better the bowel prep, the higher the adenoma detection rate.
We track all of these quality measures and report these statistics to StopColonCancerNow and CMS. Most hospitals do not follow these quality measures, so the implementation of these standards makes StopColonCancerNow surgery centers superior.
Dr. Brown attended medical school at the University of Louisville, where he was Chief Medical Resident. He completed a fellowship in Gastroenterology at the University of Louisville and has dedicated his career to serving the Louisville community in the field of gastroenterology. Among his many achievements, Dr. Brown has authored several articles relating to gastroenterology and has been voted “Top Doc” by his peers in seven successive surveys in Louisville Magazine. To learn more about Dr. Paul E. Brown and his gastroenterology practice, please visit louisvillegastroenterology.com.
Louisville Endoscopy Center, was recently honored again by the American Society for Gastrointestinal Endoscopy's (ASGE) Endoscopy Unit Recognition Program for demonstrating "a commitment to delivering quality and safety as reflected in their unit policies, credentialing, staff training and competency assessment, and quality improvement activities."