November 14, 2006
Prospects
New Tests, New Future for Doctors
By GINA KOLATA
Gastroenterologists are worried about their future.
The problem, as some of them see it, is that they have become so dependent on using colonoscopy to screen for cancer that many do little else. But the advent of new methods of detecting colon cancer could shove them out of the screening business.
If that happens, what will gastroenterologists do? A committee of the American Gastroenterological Association says it is time to think about this possibility.
It would not be the first time that the profession has had to change.
A decade or so ago, gastroenterologists spent much of their time putting scopes down patients' throats and into their stomachs to look for ulcers. But over the last 20 years, for reasons that are not entirely clear, Helicobacter pylori, the bacterium that causes most ulcers, began to disappear in this country. Patients with chronic ulcers became less and less common.
Asked how much chronic ulcers have diminished in incidence, Dr. Robert S. Sandler, chief of the division of gastroenterology and hepatology at the University of North Carolina, replied, "I can't give you a statistic, but a lot."
But by chance, as endoscopies waned, a new test surged. This time, the focus was on the other end of the intestinal tract, the colon. By the late 1990s, people over age 50 were reporting to their doctors for screening colonoscopies, in which a gastroenterologist would thread a scope into the colon to look for cancer or for polyps, which can turn into cancer.
Medical groups recommended colon cancer screening. In 2001, Medicare said it would pay for the tests. And suddenly, gastroenterologists were doing colonoscopies almost full time.
The number of colonoscopies among Medicare recipients increased by 42 percent from 2000, when Medicare would pay only if patients were likely to have polyps or cancer, to 2002, when Medicare agreed to pay for colonoscopies as a screening test.
In 2000, Medicare paid for 2,211,925 colonoscopies; by 2002 the figure had risen to 3,150,738. Soon, demand was so great that no matter how many colonoscopies doctors did, there were long lines of patients waiting to be screened.
Those who needed to see gastroenterologists for other reasons often had long waits for appointments, said Dr. Douglas Rex, a gastroenterologist and professor of medicine at the Indiana University School of Medicine.
Gastroenterologists enjoy doing colonoscopies and believe they are important, because colon cancer is the most preventable cancer, Dr. Rex said. And, he added, there is a financial disincentive for treating patients with diseases like hepatitis or conditions like irritable bowel syndrome, which often require extensive, and poorly compensated, discussions with patients to help them cope.
Now, though, the colonoscopy era may be coming to an end, the gastroenterology association's Future Trends Committee said. The panel predicted that before long, most colon cancer screening could be done by radiologists with CT scans or even by general practitioners who send stool samples off for tests looking for cancer cells. Or patients may swallow a pill containing a camera that will show images of the colon, a method that is being tested now in the upper gastrointestinal tract.
So far, Medicare and other insurers do not generally pay for the CT scans to screen the colon, but that is expected to change as the technology improves.
With a CT scan, as with colonoscopies, patients have to take powerful laxatives ahead of time to cleanse their bowels. But for the actual test, they simply lie down and hold their breath for about 10 seconds, exhale, then hold their breath again while a scanner X-rays their colons, creating detailed, three-dimensional images.
With traditional colonoscopy, patients are sedated while a doctor threads a long tube into the colon. It takes about half an hour to examine the colon's walls. Then the patients wait in a recovery room for about an hour as the sedative wears off.
Of course, if CT scans or other screening methods replace colonoscopy, the very nature of gastroenterologists' practice will be altered, said Dr. Timothy Cragin Wang, chief of the division of digestive and liver diseases at Columbia University Medical Center and the chairman of the gastroenterological association's committee. And, he added, "obviously it has economic consequences."
"Things change very quickly," Dr. Wang said. "Dependence of a specialty on a single procedure is always a concern."
His committee suggested that gastroenterologists think about what else they might do. Maybe obesity treatment, the group said, or perhaps more of a focus on liver disease or actually treating colon cancer instead of just finding it.
Or maybe gastroenterologists will not have to cede CT screening to radiologists after all. Why couldn't a gastroenterologist read a CT scan of the colon? If that is the direction they want to go, gastroenterologists can look to cardiologists for inspiration, Dr. Wang added.
In cardiology, when angiograms were developed to look at the heart, cardiologists invented a new subspecialty to do those tests themselves. They could have let radiologists take over angiography, but they didn't.
Now these interventional cardiologists are expanding, going beyond the heart to blood vessels all over the body, putting stents into carotid arteries that feed the brain and into blocked blood vessels in the legs.
"There are big political battles between the medical societies over who controls imaging," Dr. Wang said. "Gastroenterologists should be involved in making the decisions on which tests should be done. They should be aware of the technology and how to use it in order to ensure that patients get the best possible care."
As the battle over colon cancer screening gets going, Dr. Wang said, "I would certainly use cardiology as an example."
Not everyone would agree that the colonoscopy era is coming to an end. Those CT scans, sometimes called virtual colonoscopies, are not necessarily going to replace most traditional colonoscopies, some skeptics say, and if a CT scan or one of the more futuristic tests does find a polyp, the patient will still need a colonoscopy to take it out.
"Dire warnings never happen," said Dr. James T. Frakes, a gastroenterologist in Rockford, Ill., and past president of the American Society for Gastrointestinal Endoscopy. "I think it always makes sense to look forward, but physicians, just by nature, are worriers. They can get so wrapped up in the worry that it paralyzes them."
And even if the demand for colonoscopies starts to slacken, Dr. Rex said, gastroenterologists still have plenty of alternatives.
"We have a lot of organs," Dr. Rex said. "The esophagus, the stomach, the small bowel, the liver, the pancreas. I think we've got a lot to do."
Gastroenterologists, he added, "will still be able to make a comfortable living."
