Colorectal cancer is the third leading cause of cancer death in the US. The American Cancer Society (ACS) reported that there will be over 95,000 new cases of colon cancer and over 39,000 cases of rectal cancer in the US in 2016. Men have a 1 in 21 lifetime risk of developing colorectal cancer whereas women have a 1 in 23 lifetime risk. It is expected to cause almost 50,000 deaths this year.
Despite these dire statistics, the death rate from colon cancer has been declining in recent years. Many people attribute this to screening and the fact that many precancerous polyps are found and removed at an early stage. Polyps in the colon are fairly common and most of them are in fact benign. The United States Preventative Task Force (USPTS) delineated very specific guidelines for colorectal cancer screening.
Who should be screened for colon cancer?
- Everyone starting at the age of 50 years old; they recommend screening until the age of 75, after which time it can continue on a patient by patient basis. They advise stopping screening over the age of 86 years for everyone.
- Patients with a significant family history of colorectal cancer or polyps should start screening before the age of 50, if indicated.
- Patients with a personal history of inflammatory bowel disease (IBD) should start screening at an earlier age.
- Patients with certain inherited disorders may also be advised to start screening at an earlier age.
The guidelines are very specific as to who should be screened. Screening tests include high-sensitivity fecal blood occult tests, stool DNA tests, and colonoscopy (either standard or virtual). While the recommendations also state that sigmoidoscopy and double barium enema are also useful as screening tests, they are rarely used any more.
Despite the fact that colorectal cancer screening has been shown to save lives, millions of people who fit the screening criteria are not being screened. Many factors play into this. Cost has been cited in the past as a colonoscopy can be a fairly expensive undertaking. However, under the Affordable Care Act (ACA), patients are no longer expected to pay for preventative health procedures. In theory, this should be a motivating factor. Unfortunately, the reality does not always match up and patients often find bills related to having these screening services done.
Another reason patients often give for not doing screening colonoscopies is the expected discomfort. In fact, the procedure is done under sedation and patients don’t feel or remember anything. They may experience boating and mild discomfort following the procedure, but this is short-lived. Most of my patients tell me that the worst part of it is the preparation for the colonoscopy, “drinking that stuff”. I tell my patients that colorectal cancer is much more painful and lasts much longer, sometimes for a lifetime. And, in some instances, people die from this disease.
People are busy these days; it is not easy to find time to go to the doctor, yet alone take a whole day off to undergo a colonoscopy. Who wants to waste a sick day or vacation day to do this? Here, we need to be very clear with our patients why they need to be doing the screening. It is not just that it is a recommended screening test for their age, like I often hear my students tell them. It is a test where, if they have a cancerous or pre-cancerous polyp, they can be diagnosed and treated at the same time. That polyp will be removed during the screening colonoscopy and there will be no need to return later for further surgeries. And it will prevent that polyp from transforming into cancer. And if the colonoscopy is clear, then the patient doesn’t need another one for ten years. In the end it saves time. The patient may end up doing the screening just so you stop harping at them. That is a job well done, in my opinion.
- Tell them the recommendations and where they are coming from. It is good that they know that you are not making this stuff up.
- Give them the statistics. They probably won’t care about preventing colorectal cancer unless they know how prevalent it is and that they might actually be a victim. No one is going to do a screening test if they don’t believe there is a clear benefit in it for them.
- Let them know their rights. Under the ACA, it is their right not to pay for preventative medicine. If their insurance company is not covering these services, they are in violation of federal law. One call to the insurance company informing some insurance adjuster of the same usually gets the job done. You may have to go to the supervisor. But, this is in your patient’s best interests. Fight for it and encourage them to do the same.
- Make it easy for them. Give them the referral, tell them what to expect, and understand what is happening.
- Follow up with them. As a primary care doctor, I am not the one doing the colonoscopy. But, I do need to see the patient back sometime in the near future to see what happened when they went and to discuss the results. Often, the specialist tells them the results following the procedure but sometimes the patient is still too groggy to retain that information. The specialist is doing nothing wrong because they always ask the patient to come back at a future date to discuss it in more detail. But, many patients never go back.
Colon cancer is the second leading cause of cancer death among men and women combined in the US. But, it shouldn’t be because we now own very good preventative tools in our fight against it. Patients may be hesitant to follow the guidelines. It is our job to convince them otherwise. While metastatic colorectal cancer is a horrible disease, it can be preventable in some, not all, cases. As clinicians, we need to step up and put these guidelines into play more universally. How many preventable cancers are too many to let develop? I say it is just one; what about you?
About the Author
Linda Girgis MD, FAAFP is a family physician practicing in South River, New Jersey. She was voted one of the top 5 healthcare bloggers in 2016. Follow her on twitter @DrLindaMD.